Jodi Rae Boerger Wilder, LP

Primary specialty

PsychologistTaxonomy code 103T00000X

License

LP4398 Issued in MN

Practice address

1245 Washington Ave
Detroit Lakes, MN 56501-3905

Phone

(218) 846-2000

Fax

(218) 846-2114

NPI assigned

Mar 16, 2006

Sex

Female

Sole proprietor

No

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Sanford Medical Center Fargo

  • Family Medicine Physician
  • West Fargo, ND
  • NPI 1184917924

  MN

  Medicare reassignment NPD
• Sanford Medical Center Fargo

  • General Acute Care Hospital
  • Fargo, ND
  • NPI 1528009412
  NPD

Medicare fee-for-service enrollment

Enrolled in MN

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

The complete NPPES record for this NPI in the NPI Registry API format, last updated by the provider on Mar 8, 2023.

{
    "created_epoch": "1142467200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1678233600000",
    "number": "1699744227",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 5074",
            "city": "SIOUX FALLS",
            "state": "SD",
            "postal_code": "571175074"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1245 WASHINGTON AVE",
            "city": "DETROIT LAKES",
            "state": "MN",
            "postal_code": "565013905",
            "telephone_number": "218-846-2000",
            "fax_number": "218-846-2114"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "900 Hilligoss Blvd SE",
            "address_purpose": "LOCATION",
            "city": "Fosston",
            "state": "MN",
            "postal_code": "565421542",
            "country_code": "US",
            "telephone_number": "218-435-1133",
            "fax_number": "218-435-1134",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "BOERGER WILDER",
        "first_name": "JODI",
        "middle_name": "RAE",
        "name_prefix": "Dr.",
        "credential": "LP",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-03-16",
        "last_updated": "2023-03-08",
        "certification_date": "2023-03-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "MN",
            "license": "LP4398",
            "primary": false
        },
        {
            "code": "103T00000X",
            "taxonomy_group": "",
            "desc": "Psychologist",
            "state": "MN",
            "license": "LP4398",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "HEALTH PARTNERS",
            "identifier": "HP37004",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "629899100",
            "state": "MN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1699744227",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS OF ND",
            "identifier": "22522",
            "state": "ND"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PREFERRED ONE",
            "identifier": "1032397",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS BHST",
            "identifier": "310T1B0",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UCARE ALTRU",
            "identifier": "171126",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UBH MEDICA",
            "identifier": "6159749",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Audrey Blommel
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• Anika Bohmer
• Juldie Lynn Bohmer, LPCC
• Melissa Boit
• Randall J. Bolar, M.D.
• Sharon Lynn Bolar, PA-C

• All providers in Detroit Lakes, MN
• Psychologist in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 8, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.