NPIMap

Organization Active NPI

Penobscot Community Health Center

Doing business as Jackman Community Health Center

  • Federally Qualified Health Center (FQHC)
  • Jackman, ME
National Provider Identifier
1669802849
Registry record updated Aug 6, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
PENOBSCOT COMMUNITY HEALTH CENTER
Doing business as
Jackman Community Health Center
Practice address
376 Main St
Jackman, ME 04945
Phone
(207) 668-4300
Fax
(207) 668-7605
NPI assigned
Nov 25, 2013
Last updated
Aug 6, 2018By the provider in NPPES
Organization subpart
Yes
Parent organization
PENOBSCOT COMMUNITY HEALTH CENTERAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Aug 6, 2018

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

Authorized official

Name
Lori L. Dwyer, ESQ.
Title
President & Ceo
Phone
(207) 992-9200

Specialties & licenses 1

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

Addresses

Primary practice location

376 Main St
Jackman, ME 04945

Mailing address

PO Box 1599
Bangor, ME 04402-1599
Phone (207) 945-5247

Other names 1

  • Jackman Community Health Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ME2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040819000698 ME Part B Supplier - Clinic/Group Practice 0143212670 Receives reassigned benefits from 154 practitioners
18 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Jackman, ME; Old Town, ME; Brewer, ME; Belfast, ME; Bangor, ME
O20131227000601 ME Part A Provider - Federally Qualified Health Center (FQHC) 0143212670 Practice locations: Jackman, ME

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1669802849. Details of each certification follow.

Federally qualified health center certification: CCN 201907

Legal name
PENOBSCOT COMMUNITY HEALTH CENTER
Doing business as
JACKMAN COMMUNITY HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jan 6, 2014
Last certification
Jan 6, 2014
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Feb 28, 2001 in ME
Enrollment address
376 Main St
Jackman, ME 49455214

Other NPIs with the same Medicare PAC ID 13

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

View all 13

Other NPIs on the same Medicare enrollment 17

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 17

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
20D0709006Jackman Community Health Center376 Main St, Jackman, ME 04945Certificate of waiverDec 4, 2026

National Provider Directory

National Provider Directory
Tax ID family
Manna Inc40 organizations share this tax ID, including this one
Part of
Manna Inc

Other organizations with this tax ID 39

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

View all 39

Ownership & related parties

All disclosed owners & managing parties 19

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

NameRoleSinceShare
Christopher Linder Individual Corporate Director Oct 1, 2020
Mark Doty Individual Corporate Director Jul 1, 2010
Shelly Okere Individual Corporate Director Oct 1, 2020
Aaron Ballman Individual Corporate Director Sep 1, 2015
Mary Ellen Dunfield Individual Corporate Director Apr 5, 2022
Daniel Williams Individual Corporate Director Mar 1, 2020
Daniel Frye Individual Corporate Director Apr 5, 2022
Kelley Strout Individual Corporate Director Nov 1, 2017
Edwin Goodwin Individual Corporate Director Dec 7, 2021
Alan Duplessis Individual Corporate Director Dec 1, 2013
Katie Spencer White Individual Corporate Director Nov 2, 2021
Christopher Winstead Individual Corporate Director Oct 1, 2012
Christine Finn-McLaughlin Individual Corporate Officer Feb 3, 2015
Corporate Director Feb 3, 2015
W-2 Managing Employee Feb 3, 2015
Operational/Managerial Control Feb 3, 2015
Carin Sychterz Individual Corporate Director Apr 1, 2016
Jennifer Eastman Individual Corporate OfficerBoard Chair Dec 1, 2009
Monique Gauteau Individual Corporate Director Apr 1, 2013
Lorelle L Dwyer Individual Corporate Officer Sep 1, 2017
Corporate Director Sep 1, 2017
W-2 Managing Employee Sep 1, 2017
Operational/Managerial Control Sep 1, 2017
Robert Paul Allen Individual Corporate Director May 16, 2016
Mark Woodward Individual Corporate OfficerBoard Vice Chair May 1, 2011

Practitioners & affiliated clinicians

Practitioners 6

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.

NPI Registry JSON

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

{
    "created_epoch": "1385337600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1533513600000",
    "number": "1669802849",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1599",
            "city": "BANGOR",
            "state": "ME",
            "postal_code": "044021599",
            "telephone_number": "207-945-5247"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "376 MAIN ST",
            "city": "JACKMAN",
            "state": "ME",
            "postal_code": "04945",
            "telephone_number": "207-668-4300",
            "fax_number": "207-668-7605"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PENOBSCOT COMMUNITY HEALTH CENTER",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PENOBSCOT COMMUNITY HEALTH CENTER",
        "enumeration_date": "2013-11-25",
        "last_updated": "2018-08-06",
        "status": "A",
        "authorized_official_last_name": "DWYER",
        "authorized_official_first_name": "LORI",
        "authorized_official_middle_name": "L.",
        "authorized_official_title_or_position": "PRESIDENT & CEO",
        "authorized_official_telephone_number": "207-992-9200",
        "authorized_official_credential": "ESQ."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Jackman Community Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Jackman, ME

Sources for this page

Verify at the official NPI Registry.