Healthcare Provider Details

I. General information

NPI: 1124390786
Provider Name (Legal Business Name): JERRY DUANE LILLY ED.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2012
Last Update Date: 09/11/2025
Certification Date: 07/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

172 S ACADEMY AVE STE 160
EAGLE ID
83616-6564
US

IV. Provider business mailing address

12073 N HUMPHREYS WAY
BOISE ID
83714-9343
US

V. Phone/Fax

Practice location:
  • Phone: 208-315-4855
  • Fax:
Mailing address:
  • Phone: 208-315-4855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLCPC-6990
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: