Provider Demographics
NPI:1699744227
Name:BOERGER WILDER, JODI RAE (LP)
Entity type:Individual
Prefix:DR
First Name:JODI
Middle Name:RAE
Last Name:BOERGER WILDER
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1245 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3905
Practice Address - Country:US
Practice Address - Phone:218-846-2000
Practice Address - Fax:218-846-2114
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4398103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
HP37004OtherHEALTH PARTNERS
MN629899100Medicaid
MN1699744227Medicaid
ND22522OtherBCBS OF ND
1032397OtherPREFERRED ONE
MN310T1B0OtherBCBS BHST
MN171126OtherUCARE ALTRU
MN6159749OtherUBH MEDICA