| Doctor Name: | DR. JODI RAE BOERGER WILDER |
| NPI Number: | 1699744227 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | LP |
| License Number: | LP4398 |
| Business Practice Address: | 900 Hilligoss Blvd Se Fosston, MN - 565421542 |
| Business Phone Number: | 2184351133 |
| Business Fax Number: | 2184351134 |
| Mailing Address: | 900 Hilligoss Blvd Se, FOSSTON |
| State: | MN |
| Postal Code: | 565421542 |
| Phone Number: | 2184351133 |
| Fax Number: | 2184351134 |
| NPI Enumeration Date: | 03/16/2006 |
| NPI Last Update Date: | 12/23/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103TC0700X |
| License Number: | LP4398 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MN |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Psychologist |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | |