NPIMap

Organization Active NPI

Jack County Hospital District

Doing business as Faith Community Hospital Rural Health Clinic

  • Rural Health Clinic/Center
  • Jacksboro, TX
National Provider Identifier
1013909936
Registry record updated Jul 21, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
License
100322 Issued in TX
Legal business name
JACK COUNTY HOSPITAL DISTRICT
Doing business as
Faith Community Hospital Rural Health Clinic
Practice address
215 Chisholm TRL
Jacksboro, TX 76458-1403
Phone
(940) 567-6633
Fax
(940) 567-2895
NPI assigned
Aug 17, 2005
Last updated
Jul 21, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 21, 2022

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

Authorized official

Name
Kim Lee
Title
Coo
Phone
(940) 567-6633

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X 000046 TX
Rural Health Clinic/Center 261QR1300X 100322 TX Primary

Addresses

Primary practice location

215 Chisholm TRL
Jacksboro, TX 76458-1403

Mailing address

215 Chisholm TRL
Jacksboro, TX 76458-1403
Phone (940) 567-6633

Other identifiers 3

IdentifierTypeStateIssuer
092126401MedicaidTX
092126403MedicaidTX
092126402MedicaidTX

Other names 1

  • FAITH COMMUNITY HOSPITAL RURAL HEALTH CLINIC Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TX

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20110627000707 TX Part A Provider - Rural Health Clinic 4587842315 Practice locations: Jacksboro, TX

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1013909936. Details of each certification follow.

Rural health clinic certification: CCN 673404

Legal name
JACK COUNTY HOSPITAL DISTRICT
Doing business as
JACK COUNTY MEDICAL CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jun 27, 2011
Last certification
Jan 13, 2016
Ownership / control type
Non-profit – church related
Organization structure
GovernmentNon-profit
Enrollment address
215 Chisholm Trail
Jack County Medical Clinic
Jacksboro, TX 76458-1403
Related CCNs
450241

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 6

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

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
45D0893093Jack County Medical Clinic215 Chisholm Trail, Jacksboro, TX 76458Certificate of waiverOct 13, 2026

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 4

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

NameRoleSinceShare
Jack County Hospital District Organization, Jacksboro, TX Operational/Managerial Control Jun 1, 2010
Kim Lee Individual Corporate DirectorChief Financial Officer Sep 1, 2015
W-2 Managing EmployeeChief Financial Officer Sep 1, 2015
Frank L Beaman Individual Corporate OfficerChief Executive Officer Jun 1, 2010 100%
Corporate DirectorChief Executive Officer Jun 1, 2010
Trina D Johnson Individual W-2 Managing EmployeeFinancial Analyst Oct 1, 2024

Owners & managing parties with NPI records 2

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

Facilities with the same owner 8

Facilities that share an organizational owner with 5% or greater ownership or operational control.

NPI Registry JSON

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

{
    "created_epoch": "1124236800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1658361600000",
    "number": "1013909936",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "215 CHISHOLM TRL",
            "city": "JACKSBORO",
            "state": "TX",
            "postal_code": "764581403",
            "telephone_number": "940-567-6633",
            "fax_number": "940-567-2895"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "215 CHISHOLM TRL",
            "city": "JACKSBORO",
            "state": "TX",
            "postal_code": "764581403",
            "telephone_number": "940-567-6633",
            "fax_number": "940-567-2895"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "JACK COUNTY HOSPITAL DISTRICT",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-08-17",
        "last_updated": "2022-07-21",
        "status": "A",
        "authorized_official_last_name": "LEE",
        "authorized_official_first_name": "KIM",
        "authorized_official_title_or_position": "COO",
        "authorized_official_telephone_number": "940-567-6633"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "TX",
            "license": "000046",
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "TX",
            "license": "100322",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "092126401",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "092126403",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "092126402",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "FAITH COMMUNITY HOSPITAL RURAL HEALTH CLINIC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Jacksboro, TX

Sources for this page

Verify at the official NPI Registry.