NPIMap

Organization Active NPI

Mathiesen Memorial Health Clinic

  • Federally Qualified Health Center (FQHC)
  • Jamestown, CA
National Provider Identifier
1255595484
Registry record updated Jul 25, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 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
Last updated
Jul 25, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 25, 2023

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

Authorized official

Name
Jacqueline Kiss
Title
Credentialing
Phone
(254) 760-0228

Specialties & licenses 3

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

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TX, CA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
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

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1255595484. Details of each certification follow.

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
OtherNon-profit
Incorporated
Apr 8, 2009 in CA
Enrollment address
18144 Seco St
Jamestown, CA 95327-9737

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
05D1088264Mathiesen Memorial Health Clinic18144 Seco St, Jamestown, CA 95327Certificate of waiverAug 19, 2026

National Provider Directory

National Provider Directory

Locations

18145 Main St
#D
Jamestown, CA 95327

18268 Main St
Jamestown, CA 95327
Phone (209) 984-4820

Ownership & related parties

All disclosed owners & managing parties 5

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

NameRoleSinceShare
John Vass Individual Corporate DirectorExecutive Director Dec 1, 2015
Mathiesen Memorial Health Clinic Organization, Jamestown, CA Non-profit Operational/Managerial Control Jan 4, 2012
Jasmin Rice Individual W-2 Managing EmployeeClinic Administrator Jul 1, 2020
Jackie Liles Individual W-2 Managing EmployeeCredentialing Mar 9, 2021
Amy Curtin Individual W-2 Managing EmployeeCfo Jan 1, 2018

Practitioners & affiliated clinicians

Practitioners 28

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.

View all 28

NPI Registry JSON

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

{
    "created_epoch": "1216166400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1690243200000",
    "number": "1255595484",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 535",
            "city": "JAMESTOWN",
            "state": "CA",
            "postal_code": "953270535",
            "telephone_number": "209-984-4820",
            "fax_number": "209-984-4825"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "18144 SECO ST",
            "city": "JAMESTOWN",
            "state": "CA",
            "postal_code": "953279737",
            "telephone_number": "209-984-4820",
            "fax_number": "209-984-4825"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "18232 Smoke St",
            "address_purpose": "LOCATION",
            "city": "Jamestown",
            "state": "CA",
            "postal_code": "953279218",
            "country_code": "US",
            "telephone_number": "209-984-4820",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "18158 Main St",
            "address_purpose": "LOCATION",
            "city": "Jamestown",
            "state": "CA",
            "postal_code": "953279254",
            "country_code": "US",
            "telephone_number": "209-984-4820",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "18268 Main St",
            "address_purpose": "LOCATION",
            "city": "Jamestown",
            "state": "CA",
            "postal_code": "953279256",
            "country_code": "US",
            "telephone_number": "209-984-4820",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "MATHIESEN MEMORIAL HEALTH CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-07-16",
        "last_updated": "2023-07-25",
        "certification_date": "2023-07-24",
        "status": "A",
        "authorized_official_last_name": "KISS",
        "authorized_official_first_name": "JACQUELINE",
        "authorized_official_title_or_position": "CREDENTIALING",
        "authorized_official_telephone_number": "254-760-0228"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QM1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Multi-Specialty",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Jamestown, CA

Sources for this page

Verify at the official NPI Registry.