CLC of Jackson, LLC
Organization Active NPI Skilled Nursing Facility · Jackson, MS
NPI 1689664765 · NPPES record last updated Aug 22, 2020
Key facts
- NPI
- 1689664765
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Skilled Nursing Facility 314000000X
- License
- 612 (MS)
- Legal business name
- CLC OF JACKSON, LLC
- Practice address
- 1600 Raymond Rd
Jackson, MS 39204-4203 - Phone
- (601) 371-1700
- Fax
- (601) 371-1006
- NPI assigned
- Oct 28, 2005
- Organization subpart
- No
Authorized official
- Name
- Mr. Douglas M. Wright Jr.
- Title
- Managing Member
- Phone
- (662) 680-3148
Owners & managing parties with NPI records 1
-
Timothy Duncan Estes, M.D.
Corporate family (same tax ID) 1
Facilities with the same owner 16
Practitioners 1
-
Timothy Duncan Estes, M.D.
Medicare Care Compare: Nursing home
- Listed as
- Pleasant Hills Community Living Center
- Overall star rating
- ★☆☆☆☆ 1 of 5
- Health inspections
- ★★☆☆☆ 2 of 5
- Staffing
- ★★★☆☆ 3 of 5
- Quality measures
- ★☆☆☆☆ 1 of 5
- Type
- Medicare and Medicaid
- Ownership
- For profit - Corporation
- Certified
- Apr 1, 1989
- Medicare certification status
- Active
- Certified beds
- 100 · 82.3 residents per day on average
- Chain
- Community Eldercare Services
- Penalties (3 years)
- 5 · fines totaling $140,123
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MS
Skilled nursing facility certification: CCN 255112
- Legal name
- CLC OF JACKSON, LLC
- Doing business as
- PLEASANT HILLS COMMUNITY LIVING CENTER
- Certification status
- Active
- Provider type (POS)
- Nursing home – SNF/NF dual certification
- Participating since
- Apr 1, 1989
- Last certification
- Dec 12, 2024
- Beds
- 100
- Ownership / control type
- Corporation
- Multi-facility organization
- Community Elder Services
- Organization structure
- LLC · Proprietary
- Incorporated
- Feb 28, 2000 in MS
- Enrollment address
- 1600 Raymond Rd
Jackson, MS 39204-4203 - Nursing home name
- PLEASANT HILLS COMMUNITY LIVING CENTER
- Affiliated entity
- COMMUNITY ELDERCARE SERVICES
All disclosed owners & managing parties 5
| Name | Role | Since | Share |
|---|---|---|---|
| Community Living Centers, LLC |
5% Or Greater Direct Ownership Interest | Feb 20, 2000 | 100% |
| Adp of the SNF | Dec 31, 2025 | ||
| Community Eldercare Services, LLC |
Operational/Managerial Control | Apr 1, 2000 | 100% |
| Adp of the SNF | Dec 31, 2025 | ||
| Ciara Brown |
Operational/Managerial Control | Dec 2, 2024 | |
| Adp of the SNF | Dec 2, 2024 | ||
| Timothy Duncan Estes |
Operational/Managerial Control | Nov 15, 2007 | |
| Adp of the SNF | Nov 15, 2007 | ||
| Douglas Wright |
5% Or Greater Indirect Ownership Interest | Mar 24, 2000 | 100% |
| Operational/Managerial Control | Mar 24, 2000 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20080312000260 | MS | Part a Provider - Skilled Nursing Facility | 2264517440 | Practice locations: Jackson, MS |
National Provider Directory
- Tax ID family
- Alcorn County LTC LLC
Locations
1600 Raymond Rd
Jackson, MS 39204
Phone (601) 371-1700
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Skilled Nursing Facility | 314000000X | 612 | MS | Yes |
Addresses
Primary practice location
1600 Raymond Rd
Jackson, MS 39204-4203
Mailing address
1600 Raymond Rd
Jackson, MS 39204-4203
Phone (601) 371-1700
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 0230178 | Medicaid | MS |
Other names
- Pleasant Hills Community Living Center
Other providers in Jackson, MS
- Ahsia M Clayton
- Patricia Clayton
- Tiffany Clayton
- Todd A Clayton
- Wendy Clayton
- Cleaning Brigade
- Clear View Vision Care
- William Cleland
- James Wesley Clements
- Charles Paul Clericuzio
All providers in Jackson, MS · Skilled Nursing Facility in Mississippi
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 22, 2020. 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.