NPIMap

Organization Active NPI

Central Mississippi Civic Improvement Association, Inc

  • Federally Qualified Health Center (FQHC)
  • Jackson, MS
National Provider Identifier
1134592777
Registry record updated Nov 4, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
CENTRAL MISSISSIPPI CIVIC IMPROVEMENT ASSOCIATION, INC
Practice address
415 Claiborne Ave
Jackson, MS 39209-5321
Phone
(601) 364-5142
NPI assigned
Nov 4, 2015
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 4, 2015

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

Authorized official

Name
Jasmin Chapman, DDS
Title
Chief Executive Officer
Phone
(601) 364-5142

Specialties & licenses 1

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

Addresses

Primary practice location

415 Claiborne Ave
Jackson, MS 39209-5321

Mailing address

3502 W Northside Dr
Jackson, MS 39213-4454

Other names 1

  • Pecan Park Elementary School-Based Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20160301000292 MS Part A Provider - Federally Qualified Health Center (FQHC) 4183533235 Practice locations: Jackson, MS

Federally qualified health center certification: CCN 251038

Legal name
CENTRAL MISSISSIPPI CIVIC IMPROVEMENT ASSOCIATION, INC
Doing business as
PECAN PARK ELEMENTARY SCHOOL-BASED CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Feb 5, 2016
Last certification
Feb 5, 2016
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Oct 6, 1970 in MS
Enrollment address
415 Claiborne Ave
Jackson, MS 39209-5321

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
25D2104703Pecan Park Elementary School-Based415 Claiborne Avenue, Jackson, MS 39209Certificate of waiverOct 6, 2026

National Provider Directory

National Provider Directory
Tax ID family
Central Mississippi Improvement Association38 organizations share this tax ID, including this one

Other organizations with this tax ID 37

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

View all 37

Ownership & related parties

All disclosed owners & managing parties 13

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

NameRoleSinceShare
Jasmin O Chapman Individual Corporate OfficerChief Executive Officer Nov 1, 2015
Operational/Managerial ControlChief Executive Officer Aug 1, 1999
Ethel L Singleton Individual Corporate DirectorBoard of Directors Mar 17, 1986
Connie a Jones Individual Corporate DirectorBoard of Directors Jan 12, 2004
Lois C Christian Individual Corporate DirectorBoard of Directors Aug 21, 2006
John Marshall Lusk Individual Corporate Director Apr 17, 2023
John Wicks Individual Corporate Director Apr 17, 2023
Christopher Gray Individual Corporate Director Apr 17, 2023
Frances a Frazier Individual Corporate DirectorBoard of Directors Nov 5, 2002
Lillie Ervin Individual Corporate DirectorBoard of Directors Aug 19, 1985
Heraclio Aguilar Individual Corporate Director Apr 17, 2023
Larry D McMillian Individual Corporate DirectorBoard of Directors Apr 21, 1997
Mary Thompson Individual Corporate Director Jul 18, 2022
Alberta Johnson Individual Corporate DirectorBoard of Directors Jan 14, 2002

All facility ownership & control disclosures 5

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

FacilityTypeRoleSince
Jackson-Hinds Comprehensive Health Center -School Based Health CenterJackson, MS, CCN 251029 Federally qualified health center Operational/Managerial Control (100%) Dec 1, 2012
Jackson-Hinds Comprehensive Health Center-Terry High School Based ClinTerry, MS, CCN 251028 Federally qualified health center 5% Or Greater Direct Ownership Interest Oct 1, 1972
Gary Road Intermediate SchoolByram, MS, CCN 251056 Federally qualified health center 5% Or Greater Direct Ownership Interest
Operational/Managerial Control		 May 1, 2017
May 1, 2017
Jackson-Hinds Comprehensive Health CenterRaymond, MS, CCN 251084 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control		 Jan 1, 2019
Dec 1, 2012
Central Mississippi Civic Improvement Association, IncRaymond, MS, CCN 251086 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Jan 1, 2019

NPI Registry JSON

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

{
    "created_epoch": "1446595200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1446595200000",
    "number": "1134592777",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3502 W NORTHSIDE DR",
            "city": "JACKSON",
            "state": "MS",
            "postal_code": "392134454"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "415 CLAIBORNE AVE",
            "city": "JACKSON",
            "state": "MS",
            "postal_code": "392095321",
            "telephone_number": "601-364-5142"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CENTRAL MISSISSIPPI CIVIC IMPROVEMENT ASSOCIATION, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-11-04",
        "last_updated": "2015-11-04",
        "status": "A",
        "authorized_official_last_name": "CHAPMAN",
        "authorized_official_first_name": "JASMIN",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "601-364-5142",
        "authorized_official_credential": "DDS"
    },
    "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": "Pecan Park Elementary School-Based",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Jackson, MS

Sources for this page

Verify at the official NPI Registry.