Mathiesen Memorial Health Clinic
Organization Active NPI Federally Qualified Health Center (FQHC) · Jamestown, CA
NPI 1255595484 · NPPES record last updated Jul 25, 2023
Key facts
- NPI
- 1255595484
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- MATHIESEN MEMORIAL HEALTH CLINIC
- Practice address
- 18144 Seco St
Jamestown, CA 95327-9737 - Phone
- (209) 984-4820
- Fax
- (209) 984-4825
- NPI assigned
- Jul 16, 2008
- Organization subpart
- No
Authorized official
- Name
- Jacqueline Kiss
- Title
- Credentialing
- Phone
- (254) 760-0228
Practitioners 27
-
Nathaniel Methot, NP
-
Steven E Shield, M.D.
-
Gina M Valente-Moore, FNP
-
Zachary Adam Cooper, M.D.
-
Dolora Dossi, PSYD
-
Sheryl Allene Goularte, MSN, PMHNP-BC
-
Thomas King, FNP
-
Ralph Edward Retherford, M.D.
-
Theresa Lynn Sales, FNP
-
Kara Sigler, RN, FNP
-
Christine Ann Elder, PA-C
-
Laura Harper, PA
-
Cecilia Lopez, PA
-
Kimberly Schauer, PA-C
-
Sean F Anderson, MD
-
Daniel J Furoy, M.D.
-
Hannah Garrett, RDH
-
Lucia Thomas Olson, LMFT
-
Kyle Proctor, DDS
-
Taya Gabrielle Stanley, L.AC.
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 05D1088264 | Mathiesen Memorial Health Clinic | Certificate of waiver | Aug 19, 2026 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in TX, CA
Federally qualified health center certification: CCN 551130
- Legal name
- MATHIESEN MEMORIAL HEALTH CLINIC
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- May 24, 2012
- Last certification
- May 24, 2012
- Ownership / control type
- For profit – corporation
- Organization structure
- Other · Non-profit
- Incorporated
- Apr 8, 2009 in CA
- Enrollment address
- 18144 Seco St
Jamestown, CA 95327-9737
All disclosed owners & managing parties 5
| Name | Role | Since | Share |
|---|---|---|---|
| John Vass |
Corporate Director |
Dec 1, 2015 | |
| Mathiesen Memorial Health Clinic |
Operational/Managerial Control | Jan 4, 2012 | |
| Jasmin Rice |
W-2 Managing Employee |
Jul 1, 2020 | |
| Jackie Liles |
W-2 Managing Employee |
Mar 9, 2021 | |
| Amy Curtin |
W-2 Managing Employee |
Jan 1, 2018 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20091110000350 | TX | Part B Supplier - Clinic/Group Practice | 1759429814 |
Receives reassigned benefits from 19 practitioners Practice locations: Jamestown, CA |
| O20120501000272 | CA | Part a Provider - Federally Qualified Health Center (FQHC) | 1759429814 | Practice locations: Jamestown, CA |
National Provider Directory
Locations
18145 Main St
#D
Jamestown, CA 95327
18158 Main St
Jamestown, CA 95327
Phone (209) 782-6446
18268 Main St
Jamestown, CA 95327
Phone (209) 984-4820
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes | ||
| Multi-Specialty Clinic/Center | 261QM1300X | |||
| Primary Care Clinic/Center | 261QP2300X |
Addresses
Primary practice location
18144 Seco St
Jamestown, CA 95327-9737
Mailing address
PO Box 535
Jamestown, CA 95327-0535
Phone (209) 984-4820
Other practice location 1
18232 Smoke St
Jamestown, CA 95327-9218
Phone (209) 984-4820
Other practice location 2
18158 Main St
Jamestown, CA 95327-9254
Phone (209) 984-4820
Other practice location 3
18268 Main St
Jamestown, CA 95327-9256
Phone (209) 984-4820
Other providers in Jamestown, CA
- Jeffrey Frank Kocher
- Michelle J Low
- Blong Roger Ly
- Alejandro Gastello Martinez
- Mathiesen Memorial Health Center
- Jarie McCoy
- Young Quoc Ngo
- Lucia Thomas Olson
- Russell Dean Park
- Shawna Patricia Parker
All providers in Jamestown, CA · Federally Qualified Health Center (FQHC) in California
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 25, 2023. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.