Aaron K. Jonan Memorial Clinic Inc.
Organization Active NPI Rural Health Clinic/Center · Jackson, KY
NPI 1477569226 · NPPES record last updated May 9, 2023
Key facts
- NPI
- 1477569226
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- License
- 900029 (KY)
- Legal business name
- AARON K. JONAN MEMORIAL CLINIC INC.
- Practice address
- 832 Highway 15 N
Jackson, KY 41339-8284 - Phone
- (606) 666-5142
- Fax
- (606) 666-4172
- NPI assigned
- Aug 1, 2006
- Organization subpart
- No
Authorized official
- Name
- Djien So
- Title
- Administrator/Access Manager
- Phone
- (606) 794-5600
Owners & managing parties with NPI records 1
Practitioners 14
-
Tammy Hickman, LPCC
-
Whitney Joseph, APRN
-
Jerri Campbell, NP
-
Stacy Robertson, PMHNP-BC
-
Raven Alexis Jones, APRN
-
Lillie Adams, LCSW
-
Haley Bloom, APRN
-
Tonya Goble, APRN, FNP-BC
-
Marikate Grogan, APRN
-
Brandi N. May, APRN
-
Betty Faye Noble, NP-C
-
Joseph Dewayne Parks, PMHNP-BC
-
Lacy D. Russell, APRN
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in KY
Rural health clinic certification: CCN 183821
- Legal name
- AARON K. JONAN MEMORIAL CLINIC, INC.
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Mar 10, 1994
- Last certification
- Nov 21, 2019
- Ownership / control type
- 1C
- Organization structure
- Corporation · Proprietary
- Incorporated
- Apr 4, 2000 in KY
- Enrollment address
- 832 Highway 15 N
Jackson, KY 41339-8284
All disclosed owners & managing parties 2
| Name | Role | Since | Share |
|---|---|---|---|
| Leonor S Pagtakhan So |
5% Or Greater Direct Ownership Interest |
Jan 1, 2020 | 50% |
| W-2 Managing Employee |
Jan 1, 2013 | 50% | |
| Djien So |
5% Or Greater Direct Ownership Interest |
Apr 4, 2000 | 50% |
| Corporate Director |
Apr 4, 2000 | 50% | |
| W-2 Managing Employee |
Apr 4, 2000 | 50% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20031218000126 | KY | Part B Supplier - Clinic/Group Practice | 5294632196 |
Receives reassigned benefits from 14 practitioners Practice locations: Jackson, KY |
| O20070125000185 | KY | Part a Provider - Rural Health Clinic | 5294632196 | Practice locations: Jackson, KY |
National Provider Directory
Locations
230 Lexington St
Lancaster, KY 40444
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatrics Physician |
208000000X | 43629 | KY | |
| Rural Health Clinic/Center | 261QR1300X | 900029 | KY | Yes |
| Family Nurse Practitioner |
363LF0000X | 3006826 | KY |
Addresses
Primary practice location
832 Highway 15 N
Jackson, KY 41339-8284
Mailing address
832 Highway 15 N
Jackson, KY 41339-8284
Phone (606) 666-5142
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 7100336880 | Medicaid | KY |
Other names
- Aaron Jonan Memorial Clinic
Other providers in Jackson, KY
- June Elizabeth Abadilla
- Melecio G Abordo Jr.
- Marcia Adams
- Courtney Brooke Addison
- Advanced Surgical Specialists of Ky, PLLC
All providers in Jackson, KY · Rural Health Clinic/Center in Kentucky
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on May 9, 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.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.