NPIMap

Organization Active NPI

County Line Primary Care

Doing business as Jackson Medical Clinic Family Health Care

  • Rural Health Clinic/Center
  • Jackson, KY
National Provider Identifier
1609378132
Registry record updated Feb 24, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
COUNTY LINE PRIMARY CARE
Doing business as
Jackson Medical Clinic Family Health Care
Practice address
1550 Highway 15 S Ste 240
Jackson, KY 41339-0709
Phone
(606) 568-1184
Fax
(606) 824-5042
NPI assigned
Feb 28, 2018
Last updated
Feb 24, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 24, 2022

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

Authorized official

Name
Jessica Ann NeaceNPI 1710386503
Title
Aprn
Phone
(606) 824-5037

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X NU Primary

Addresses

Primary practice location

1550 Highway 15 S Ste 240
Jackson, KY 41339-0709

Mailing address

41 John Maco Dr
Jackson, KY 41339-6515
Phone (606) 568-1184

Other names 1

  • Jackson Medical Clinic Family Health Care Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in KY2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20200512003100 KY Part B Supplier - Clinic/Group Practice 0547691289 Receives reassigned benefits from 11 practitioners
Practice locations: Jackson, KY
O20200630002169 KY Part A Provider - Rural Health Clinic 0547691289 Practice locations: Jackson, KY

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1609378132. Details of each certification follow.

Rural health clinic certification: CCN B03827

Legal name
COUNTY LINE PRIMARY CARE
Doing business as
JACKSON MEDICAL CLINIC FAMILY HEALTH CARE
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Feb 4, 2021
Last certification
Jan 26, 2024
Ownership / control type
2B
Organization structure
LLCProprietary
Incorporated
Feb 24, 2020 in KY
Enrollment address
1550 Highway 15 S
Ste 240
Jackson, KY 41339-0709

National Provider Directory

National Provider Directory

Locations

9221 Ky 15 S
Campton, KY 41301
Phone (606) 568-1184

1550 Highway 15 S
Ste 240
Jackson, KY 41339
Phone (606) 568-1184

Ownership & related parties

All disclosed owners & managing parties 3

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

NameRoleSinceShare
Jessica Ann Neace Individual 5% Or Greater Direct Ownership InterestCo Owner Feb 26, 2020 5%
Justin Neace Individual 5% Or Greater Direct Ownership InterestCfo Apr 30, 2024 45%
Corporate OfficerCfo Feb 24, 2020
Operational/Managerial ControlCfo Feb 24, 2020
Jerry Lee Campbell Individual 5% Or Greater Direct Ownership InterestCoo Apr 30, 2024 50%
Corporate OfficerCoo Feb 24, 2020
W-2 Managing EmployeeCoo Feb 24, 2020
Operational/Managerial ControlCoo Feb 24, 2020

Owners & managing parties with NPI records 2

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

Practitioners & affiliated clinicians

Practitioners 13

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 13

NPI Registry JSON

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

{
    "created_epoch": "1519776000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1645660800000",
    "number": "1609378132",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "41 JOHN MACO DR",
            "city": "JACKSON",
            "state": "KY",
            "postal_code": "413396515",
            "telephone_number": "606-568-1184"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1550 HIGHWAY 15 S STE 240",
            "city": "JACKSON",
            "state": "KY",
            "postal_code": "413390709",
            "telephone_number": "606-568-1184",
            "fax_number": "606-824-5042"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COUNTY LINE PRIMARY CARE",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-02-28",
        "last_updated": "2022-02-24",
        "certification_date": "2022-02-24",
        "status": "A",
        "authorized_official_last_name": "NEACE",
        "authorized_official_first_name": "JESSICA",
        "authorized_official_middle_name": "ANN",
        "authorized_official_title_or_position": "APRN",
        "authorized_official_telephone_number": "606-824-5037"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Jackson Medical Clinic Family Health Care",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Jackson, KY

Sources for this page

Verify at the official NPI Registry.