Healthcare Provider Details

I. General information

NPI: 1467718932
Provider Name (Legal Business Name): JENNIFER NICOLE LILLEMON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2012
Last Update Date: 05/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E IDAHO ST STE 304
BOISE ID
83712
US

IV. Provider business mailing address

100 E IDAHO ST STE 304
BOISE ID
83712-6269
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-7040
  • Fax:
Mailing address:
  • Phone: 208-381-7040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License NumberMD177334
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: