Active NPI
Jerilyn Marie Wiederholt, PSYCHOLOGIST
- Clinical Psychologist
- Northfield, MN
National Provider Identifier
1962691501
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- 3079
- Practice address
- 209 Spring St N
Northfield, MN 55057-1432 - Phone
- (507) 645-4687
- NPI assigned
- Oct 19, 2007
- Sex
- Female
- 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 |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | 3079 | MN | Primary |
Addresses
Primary practice location
209 Spring St N
Northfield, MN 55057-1432
Mailing address
209 Spring St N
Northfield, MN 55057-1432
Phone (507) 645-4687
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 3079 | Other | MN | PSYCHOLOGIST LICENSE |
| 066327100 | Medicaid | MN |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Master of Science - Law
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 3079 | MN | MD | Clinical Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1192752000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1645574400000",
"number": "1962691501",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "209 SPRING ST N",
"city": "NORTHFIELD",
"state": "MN",
"postal_code": "550571432",
"telephone_number": "507-645-4687"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "209 SPRING ST N",
"city": "NORTHFIELD",
"state": "MN",
"postal_code": "550571432",
"telephone_number": "507-645-4687"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WIEDERHOLT",
"first_name": "JERILYN",
"middle_name": "MARIE",
"credential": "PSYCHOLOGIST",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2007-10-19",
"last_updated": "2022-02-23",
"certification_date": "2021-11-04",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "MN",
"license": "3079",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "PSYCHOLOGIST LICENSE",
"identifier": "3079",
"state": "MN"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "066327100",
"state": "MN"
}
],
"endpoints": [],
"other_names": []
}Other providers in Northfield, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 23, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.