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Organization Active NPI

Charles Drew Health Center, Inc

  • Federally Qualified Health Center (FQHC)
  • Omaha, NE
National Provider Identifier
1720335284
Registry record updated Mar 19, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
CHARLES DREW HEALTH CENTER, INC
Practice address
600 South 27TH Street
Omaha, NE 68105-1502
Phone
(402) 457-1243
Fax
(402) 453-1970
NPI assigned
Aug 14, 2012
Organization subpart
Yes
Parent organization
CHARLES DREW HEALTH CENTER, INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Mar 19, 2021

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

Authorized official

Name
Ms. Tarsha Denise Jackson
Title
Chief Financial Officer
Phone
(402) 457-1215

Specialties & licenses 7

Specialty (taxonomy)CodeLicenseStatePrimary
Addiction (Substance Use Disorder) CounselorGroup: 193200000X MULTI-SPECIALTY GROUP 101YA0400X
Mental Health CounselorGroup: 193200000X MULTI-SPECIALTY GROUP 101YM0800X
PsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103T00000X
Community Health Clinic/Center 261QC1500X NE
Federally Qualified Health Center (FQHC) 261QF0400X NE Primary
Community Health Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LC1500X
Community Health Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LC1500X NE

Addresses

Primary practice location

600 South 27TH Street
Omaha, NE 68105-1502

Mailing address

PO Box 30019
2915 Grant Street
Omaha, NE 68111-3863
Phone (402) 451-3553

Other identifiers 2

IdentifierTypeStateIssuer
100262762-00OtherNENON-FQHC
100262761-00MedicaidNE

Other names 1

  • Charles Drew Health Center, Inc at Jackson Tower Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NE

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20121008000071 NE Part A Provider - Federally Qualified Health Center (FQHC) 9830170653 Practice locations: Omaha, NE

Federally qualified health center certification: CCN 281823

Legal name
CHARLES DREW HEALTH CENTER INC
Doing business as
CHARLES DREW HEALTH CENTER, INC AT JACKSON TOWER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 30, 2012
Last certification
Nov 30, 2012
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Jan 1, 1973 in NE
Enrollment address
600 S 27TH St
Omaha, NE 68105-1502

Other NPIs with the same Medicare PAC ID 11

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

National Provider Directory

National Provider Directory
Tax ID family
Benson Community Health Center19 organizations share this tax ID, including this one
Part of
Benson Community Health Center

Other organizations with this tax ID 18

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

View all 18

Ownership & related parties

All disclosed owners & managing parties 2

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

NameRoleSinceShare
Kenny McMorris Individual 5% Or Greater Direct Ownership InterestCeo Jan 1, 2016 20%
Corporate DirectorCeo Jan 1, 2016 20%
W-2 Managing EmployeeCeo Jan 1, 2016 20%
Tarsha Jackson Individual 5% Or Greater Direct Ownership InterestCfo Jan 1, 2016 20%
Corporate DirectorCfo Jan 1, 2016 20%

NPI Registry JSON

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

{
    "created_epoch": "1344902400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1616112000000",
    "number": "1720335284",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 30019",
            "address_2": "2915 GRANT STREET",
            "city": "OMAHA",
            "state": "NE",
            "postal_code": "681113863",
            "telephone_number": "402-451-3553",
            "fax_number": "402-457-1220"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "600 SOUTH 27TH STREET",
            "city": "OMAHA",
            "state": "NE",
            "postal_code": "681051502",
            "telephone_number": "402-457-1243",
            "fax_number": "402-453-1970"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CHARLES DREW HEALTH CENTER, INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CHARLES DREW HEALTH CENTER, INC",
        "enumeration_date": "2012-08-14",
        "last_updated": "2021-03-19",
        "certification_date": "2021-03-19",
        "status": "A",
        "authorized_official_last_name": "JACKSON",
        "authorized_official_first_name": "TARSHA",
        "authorized_official_middle_name": "DENISE",
        "authorized_official_title_or_position": "CHIEF FINANCIAL OFFICER",
        "authorized_official_telephone_number": "402-457-1215",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "101YA0400X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "101YM0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Mental Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "103T00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QC1500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Community Health",
            "state": "NE",
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NE",
            "license": null,
            "primary": true
        },
        {
            "code": "363LC1500X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Community Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LC1500X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Community Health",
            "state": "NE",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NON-FQHC",
            "identifier": "100262762-00",
            "state": "NE"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100262761-00",
            "state": "NE"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Charles Drew Health Center, Inc at Jackson Tower",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Charles Drew Health Center, Inc at Jackson Tower",
            "code": "5",
            "type": "Other Name"
        },
        {
            "organization_name": "Charles Drew Health Center, Inc at Jackson Tower",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Omaha, NE

Sources for this page

Verify at the official NPI Registry.