Active NPI
Jerry Duane Lilly, ED.S
- Professional Counselor
- Eagle, ID
National Provider Identifier
1124390786
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Professional Counselor
- License
- LCPC-6990
- Practice address
- 172 S Academy Ave Ste 160
Eagle, ID 83616-6564 - Phone
- (208) 315-4855
- NPI assigned
- Jan 29, 2012
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Professional Counselor | 101YP2500X | LCPC-6990 | ID | Primary |
Addresses
Primary practice location
172 S Academy Ave Ste 160
Eagle, ID 83616-6564
Mailing address
12073 N Humphreys Way
Boise, ID 83714-9343
Phone (208) 315-4855
Other practice location 1
12073 N Humphreys Way
Boise, ID 83714-9343
Phone (208) 315-4855
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Opted out of Medicare
- Previously, effective Jul 31, 2024 through Jul 31, 2026
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| LCPC-6990 | ID | MD | Professional Counselor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1327795200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1757548800000",
"number": "1124390786",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "12073 N HUMPHREYS WAY",
"city": "BOISE",
"state": "ID",
"postal_code": "837149343",
"telephone_number": "208-315-4855"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "172 S ACADEMY AVE STE 160",
"city": "EAGLE",
"state": "ID",
"postal_code": "836166564",
"telephone_number": "208-315-4855"
}
],
"practiceLocations": [
{
"address_1": "12073 N Humphreys Way",
"address_purpose": "LOCATION",
"city": "Boise",
"state": "ID",
"postal_code": "837149343",
"country_code": "US",
"telephone_number": "208-315-4855",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"last_name": "LILLY",
"first_name": "JERRY",
"middle_name": "DUANE",
"credential": "ED.S",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2012-01-29",
"last_updated": "2025-09-11",
"certification_date": "2023-07-04",
"status": "A"
},
"taxonomies": [
{
"code": "101YP2500X",
"taxonomy_group": "",
"desc": "Counselor, Professional",
"state": "ID",
"license": "LCPC-6990",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Eagle, ID
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 11, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.