Provider Demographics
NPI:1427119254
Name:LANE, JILL MARIE (OD)
Entity type:Individual
Prefix:DR
First Name:JILL
Middle Name:MARIE
Last Name:LANE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:JILL
Other - Middle Name:MARIE
Other - Last Name:DEKAYE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:217 SE 10TH ST
Mailing Address - Street 2:
Mailing Address - City:GRANGEVILLE
Mailing Address - State:ID
Mailing Address - Zip Code:83530-5127
Mailing Address - Country:US
Mailing Address - Phone:208-983-3494
Mailing Address - Fax:
Practice Address - Street 1:405 E MAIN ST
Practice Address - Street 2:
Practice Address - City:GRANGEVILLE
Practice Address - State:ID
Practice Address - Zip Code:83530-2239
Practice Address - Country:US
Practice Address - Phone:208-983-3732
Practice Address - Fax:208-983-3738
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100095152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2031383Medicaid
IDV7168OtherBLUE CROSS OF IDAHO
ID807324600Medicaid
ID807324600Medicaid
ID1594524Medicare ID - Type Unspecified