NPIMap

Jefferson Comprehensive Care System, Inc

Organization Active NPI Federally Qualified Health Center (FQHC) · North Little Rock, AR

NPI 1003353111 · NPPES record last updated Jan 26, 2017

Key facts

NPI
1003353111
Entity type
Organization (NPI type 2)
Primary specialty
Federally Qualified Health Center (FQHC) 261QF0400X
Legal business name
JEFFERSON COMPREHENSIVE CARE SYSTEM, INC
Practice address
2525 Willow St
Suite # 1
North Little Rock, AR 72114-2213
Phone
(870) 543-2380
NPI assigned
Jan 26, 2017
Organization subpart
Yes
Parent organization (as reported)
JEFFERSON COMPREHENSIVE CARE SYSTEM, INC

Authorized official

Name
Ms. Sandra Brown
Title
Ceo
Phone
(870) 543-2300

Owners & managing parties with NPI records 2

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Owned or controlled facilities with NPI records 2

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Other NPIs on the same Medicare enrollment 7

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Other NPIs with the same Medicare PAC ID 8

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Corporate family (same tax ID) 11

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners 13

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

Laboratory certificates & supplier records

Name & address match These CMS records do not include an NPI. They are shown here because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
04D2126478North Little Rock Community Health Center
2525 Willow, North Little Rock, AR 72114		Provider-performed microscopyFeb 27, 2027

Medicare participation

Medicare fee-for-service enrollment
Enrolled (2 enrollments) in AR

Federally qualified health center certification: CCN 041925

Legal name
JEFFERSON COMPREHENSIVE CARE SYSTEM, INC
Doing business as
NORTH LITTLE ROCK COMMUNITY HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jul 24, 2017
Last certification
Jul 24, 2017
Ownership / control type
For profit – corporation
Organization structure
Corporation · Non-profit
Incorporated
Dec 8, 2016 in AR
Enrollment address
2525 Willow St
Ste 1
Little Rock, AR 72114-2213

All disclosed owners & managing parties 16

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Diann Williams
Individual 		Corporate Officer
Board Member		 Feb 1, 2016 1.47%
Eduardo R. Ochoa
Individual 		Corporate Officer
Board Member		 Feb 1, 2016 1.47%
Mary Grant
Individual 		Corporate Officer
Board Member		 Feb 1, 2016 1.47%
Ivan Hudson
Individual 		Corporate Officer
Board Member		 Feb 1, 2016 1.47%
Cheryl Broughton
Individual 		Corporate Officer
Board Member		 Feb 1, 2016 1.47%
Nikki Thornton
Individual 		Corporate Officer
Board Member		 Feb 1, 2016 1.47%
Chanda Evans-McField
Individual 		Corporate Officer
Cfo		 Oct 1, 2010
Albert Lowery
Individual 		Corporate Officer
Board Member		 Feb 1, 2016 1.47%
Sandra J Brown
Individual 		Corporate Director Sep 18, 2012
W-2 Managing Employee Mar 10, 2010
Zackery Tallaferro
Individual 		Corporate Officer
Board Member		 Feb 1, 2016 1.47%
Patricia Ballard
Individual 		Corporate Officer
Board Member		 Feb 1, 2016 1.47%
Patricia a Washington
Individual 		Corporate Director May 13, 2013
W-2 Managing Employee May 13, 2013
Kevin Storey
Individual 		Corporate Officer
Board Member		 Feb 1, 2016 1.47%
Chris Barron
Individual 		Corporate Officer
Board Member		 Feb 1, 2016 1.47%
Stephanie Stanton
Individual 		Corporate Officer
Board Member		 Feb 1, 2016 1.47%
Earnestine Daniels
Individual 		Corporate Officer
Board Member		 Feb 1, 2016 1.47%

All facility ownership & control disclosures 2

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Downtown Little Rock Community Health Center
Little Rock, AR · CCN 041055		 Federally qualified health center 5% Or Greater Direct Ownership Interest Nov 30, 1972
Jefferson Comprehensive Care System, Inc
Little Rock, AR · CCN 041051		 Federally qualified health center 5% Or Greater Direct Ownership Interest Nov 30, 1972

Medicare enrollment records

Enrollment IDStateProvider typePAC IDDetails
O20040603001458 AR Part B Supplier - Clinic/Group Practice 5193634509 Receives reassigned benefits from 22 practitioners
7 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Altheimer, AR; Redfield, AR; Pine Bluff, AR; North Little Rock, AR; Little Rock, AR; College Station, AR
O20170721000654 AR Part a Provider - Federally Qualified Health Center (FQHC) 5193634509 Practice locations: Little Rock, AR

National Provider Directory

Tax ID family
Pine Bluff Health Clinic (12 organizations share this tax ID)
Part of
Pine Bluff Health Clinic

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Yes

Addresses

Primary practice location

2525 Willow St
Suite # 1
North Little Rock, AR 72114-2213

Mailing address

PO Box 1285
Pine Bluff, AR 71613-1285
Phone (870) 543-2311

Other names

  • NORTH LITTLE ROCK COMMUNITY HEALTH CENTER Other name

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Jan 26, 2017.

{
    "created_epoch": "1485388800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1485388800000",
    "number": "1003353111",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1285",
            "city": "PINE BLUFF",
            "state": "AR",
            "postal_code": "716131285",
            "telephone_number": "870-543-2311"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2525 WILLOW ST",
            "address_2": "SUITE # 1",
            "city": "NORTH LITTLE ROCK",
            "state": "AR",
            "postal_code": "721142213",
            "telephone_number": "870-543-2380"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "JEFFERSON COMPREHENSIVE CARE SYSTEM, INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "JEFFERSON COMPREHENSIVE CARE SYSTEM, INC",
        "enumeration_date": "2017-01-26",
        "last_updated": "2017-01-26",
        "status": "A",
        "authorized_official_last_name": "BROWN",
        "authorized_official_first_name": "SANDRA",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "870-543-2300",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "NORTH LITTLE ROCK COMMUNITY HEALTH CENTER",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in North Little Rock, AR

All providers in North Little Rock, AR · Federally Qualified Health Center (FQHC) in Arkansas

Sources for this page

Verify at the official NPI Registry.