Healthcare Provider Details

I. General information

NPI: 1093912479
Provider Name (Legal Business Name): JESSICA LILLEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 11/16/2023
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 W JEFFERSON ST
TUPELO MS
38804-3936
US

IV. Provider business mailing address

7731 OLD CANTON RD STE B
MADISON MS
39110-6115
US

V. Phone/Fax

Practice location:
  • Phone: 624-320-2006
  • Fax: 662-432-0199
Mailing address:
  • Phone: 601-499-0935
  • Fax: 601-499-0936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMT191145
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number22722
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: