Provider Demographics
NPI:1467718932
Name:LILLEMON, JENNIFER NICOLE (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:NICOLE
Last Name:LILLEMON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E IDAHO ST STE 304
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6269
Mailing Address - Country:US
Mailing Address - Phone:208-381-7040
Mailing Address - Fax:
Practice Address - Street 1:100 E IDAHO ST STE 304
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712
Practice Address - Country:US
Practice Address - Phone:208-381-7040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-09
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD177334207VF0040X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyFemale Pelvic Medicine and Reconstructive Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program