Individual
JERILYN MARIE WIEDERHOLT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PSYCHOLOGIST
Contact information
Practice address
209 SPRING ST N, NORTHFIELD, MN 55057-1432
(507) 645-4687
Mailing address
209 SPRING ST N, NORTHFIELD, MN 55057-1432
(507) 645-4687
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
3079
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
066327100
—
MN
01
—
3079
PSYCHOLOGIST LICENSE
MN
Enumeration date
10/19/2007
Last updated
02/23/2022
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