Provider Demographics
NPI:1043891690
Name:LILLEY, JENNIFER LYNN (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:LILLEY
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 1:955 POWELL AVE SW
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-2908
Mailing Address - Country:US
Mailing Address - Phone:425-277-1311
Mailing Address - Fax:425-277-1566
Practice Address - Street 1:923 AUBURN WAY N
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-4117
Practice Address - Country:US
Practice Address - Phone:253-351-3900
Practice Address - Fax:253-804-3222
Is Sole Proprietor?:No
Enumeration Date:2021-04-15
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXV0020207Q00000X
TX390200000X
WAMD61575279207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program