NPIMap

Organization Active NPI

Jefferson Comprehensive Care System, Inc

  • Federally Qualified Health Center (FQHC)
  • North Little Rock, AR
National Provider Identifier
1003353111
Registry record updated Jan 26, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 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
Last updated
Jan 26, 2017By the provider in NPPES
Organization subpart
Yes
Parent organization
JEFFERSON COMPREHENSIVE CARE SYSTEM, INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jan 26, 2017

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

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

Specialties & licenses 1

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

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 1

  • NORTH LITTLE ROCK COMMUNITY HEALTH CENTER Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AR2 enrollments

Enrollment records 2

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

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1003353111. Details of each certification follow.

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
CorporationNon-profit
Incorporated
Dec 8, 2016 in AR
Enrollment address
2525 Willow St
Ste 1
Little Rock, AR 72114-2213

Other NPIs with the same Medicare PAC ID 8

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

Other NPIs on the same Medicare enrollment 7

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

Laboratory certificates & supplier records

Derived by NPIMap

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

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
04D2126478North Little Rock Community Health Center2525 Willow, North Little Rock, AR 72114Provider-performed microscopyFeb 27, 2027

National Provider Directory

National Provider Directory
Tax ID family
Jefferson Comprehensive12 organizations share this tax ID, including this one
Part of
Jefferson Comprehensive

Other organizations with this tax ID 11

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

Ownership & related parties

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 OfficerBoard Member Feb 1, 2016 1.47%
Eduardo R. Ochoa Individual Corporate OfficerBoard Member Feb 1, 2016 1.47%
Mary Grant Individual Corporate OfficerBoard Member Feb 1, 2016 1.47%
Ivan Hudson Individual Corporate OfficerBoard Member Feb 1, 2016 1.47%
Cheryl Broughton Individual Corporate OfficerBoard Member Feb 1, 2016 1.47%
Nikki Thornton Individual Corporate OfficerBoard Member Feb 1, 2016 1.47%
Chanda Evans-McField Individual Corporate OfficerCfo Oct 1, 2010
Albert Lowery Individual Corporate OfficerBoard 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 OfficerBoard Member Feb 1, 2016 1.47%
Patricia Ballard Individual Corporate OfficerBoard 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 OfficerBoard Member Feb 1, 2016 1.47%
Chris Barron Individual Corporate OfficerBoard Member Feb 1, 2016 1.47%
Stephanie Stanton Individual Corporate OfficerBoard Member Feb 1, 2016 1.47%
Earnestine Daniels Individual Corporate OfficerBoard Member Feb 1, 2016 1.47%

Owners & managing parties with NPI records 2

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

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 CenterLittle Rock, AR, CCN 041055 Federally qualified health center 5% Or Greater Direct Ownership Interest Nov 30, 1972
Jefferson Comprehensive Care System, IncLittle Rock, AR, CCN 041051 Federally qualified health center 5% Or Greater Direct Ownership Interest Nov 30, 1972

Owned or controlled facilities with NPI records 2

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

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "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

Sources for this page

Verify at the official NPI Registry.