Healthcare Provider Details

I. General information

NPI: 1043891690
Provider Name (Legal Business Name): JENNIFER LYNN LILLEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2021
Last Update Date: 07/08/2025
Certification Date: 07/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 4TH ST
LUBBOCK TX
79430-0002
US

IV. Provider business mailing address

955 POWELL AVE SW
RENTON WA
98057-2908
US

V. Phone/Fax

Practice location:
  • Phone: 806-743-2757
  • Fax: 806-743-1180
Mailing address:
  • Phone: 425-277-1311
  • Fax: 425-277-1566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD61575279
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberV0020
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: