NPIMap

Organization Active NPI

Jefferson County Public Hospital District No 2

Doing business as South County Medical Clinic

  • Rural Health Clinic/Center
  • Quilcene, WA
National Provider Identifier
1780897074
Registry record updated Dec 31, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
JEFFERSON COUNTY PUBLIC HOSPITAL DISTRICT NO 2
Doing business as
South County Medical Clinic
Practice address
294843 State Highway 101
Quilcene, WA 98376
Phone
(360) 765-3111
Fax
(360) 765-3811
NPI assigned
May 7, 2007
Last updated
Dec 31, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 31, 2025

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

Authorized official

Name
Mike Glenn
Title
Ceo
Phone
(360) 385-2200

Specialties & licenses 1

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

Addresses

Primary practice location

294843 State Highway 101
Quilcene, WA 98376

Mailing address

PO Box 104546
Pasadena, CA 91189-4546
Phone (360) 385-2200

Other identifiers 1

IdentifierTypeStateIssuer
7056401MedicaidWA

Other names 1

  • South County Medical Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031111000542 WA Part B Supplier - Clinic/Group Practice 4789593708 Receives reassigned benefits from 231 practitioners
9 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Quilcene, WA; Port Townsend, WA; Port Ludlow, WA; Bellingham, WA
O20100927000358 WA Part A Provider - Rural Health Clinic 4789593708 Practice locations: Quilcene, WA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1780897074. Details of each certification follow.

Rural health clinic certification: CCN 503997

Legal name
JEFFERSON COUNTY PUBLIC HOSPITAL DISTRICT NO 2
Doing business as
SOUTH COUNTY MEDICAL CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jun 6, 1996
Last certification
May 16, 2017
Ownership / control type
Non-profit – church related
Organization structure
CorporationProprietary
Incorporated
Oct 1, 1976 in WA
Enrollment address
294843 US Highway 101
Quilcene, WA 98376-9800
Related CCNs
501323

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 9

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

Other NPIs on the same Medicare enrollment 9

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

National Provider Directory

National Provider Directory
Tax ID family
G Forbes K Forbes MDS6 organizations share this tax ID, including this one

Other organizations with this tax ID 5

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

Locations

934 Sheridan St
Port Townsend, WA 98368
Phone (360) 385-5330

Ownership & related parties

All disclosed owners & managing parties 8

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

NameRoleSinceShare
Bruce McComas Individual Corporate OfficerBoard of Commissioners Jan 1, 2018
Cornelis Kolff Individual Corporate OfficerBoard of Commissioners Jan 1, 2016
Tyler Freeman Individual Corporate OfficerCfo Jan 1, 2022
Operational/Managerial ControlCfo Jan 1, 2022
Brandie Manuel Individual Corporate OfficerChief Patient Care Officer Nov 12, 2020
Corporate DirectorChief Patient Care Officer Nov 12, 2020
Matthew W Ready Individual Corporate DirectorBoard of Commissoners Jan 1, 2014
Lawrence M Glenn Individual Corporate OfficerCeo Oct 4, 2010
Operational/Managerial ControlCeo Oct 4, 2010
Jill E Buhler Individual Corporate DirectorBoard of Commissioners Mar 2, 1995
Marie L Dressler Individual Corporate DirectorBoard of Commissoners Jan 1, 2010

All facility ownership & control disclosures 2

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Jefferson Healthcare Home HealthPort Townsend, WA, CCN 507050 Home health agency Operational/Managerial Control Jan 1, 2003
Jefferson Healthcare Home Health and HospicePort Townsend, WA, CCN 501538 Hospice Operational/Managerial Control Aug 5, 2010

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 30

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 30

NPI Registry JSON

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

{
    "created_epoch": "1178496000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1767139200000",
    "number": "1780897074",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 104546",
            "city": "PASADENA",
            "state": "CA",
            "postal_code": "911894546",
            "telephone_number": "360-385-2200"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "294843 STATE HIGHWAY 101",
            "city": "QUILCENE",
            "state": "WA",
            "postal_code": "98376",
            "telephone_number": "360-765-3111",
            "fax_number": "360-765-3811"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "JEFFERSON COUNTY PUBLIC HOSPITAL DISTRICT NO 2",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-05-07",
        "last_updated": "2025-12-31",
        "certification_date": "2025-12-31",
        "status": "A",
        "authorized_official_last_name": "GLENN",
        "authorized_official_first_name": "MIKE",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "360-385-2200"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7056401",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "South County Medical Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "South County Medical Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Quilcene, WA

Sources for this page

Verify at the official NPI Registry.