NPIMap

Organization Active NPI

Jefferson County Public Hospital District No 2

Doing business as Jefferson Healthcare Port Ludlow Clinic

  • Rural Health Clinic/Center
  • Port Ludlow, WA
National Provider Identifier
1801188073
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
Jefferson Healthcare Port Ludlow Clinic
Practice address
89 Breaker LN
Port Ludlow, WA 98365-9766
Phone
(360) 385-2200
Fax
(360) 379-2282
NPI assigned
May 6, 2011
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 NU Primary

Addresses

Primary practice location

89 Breaker LN
Port Ludlow, WA 98365-9766

Mailing address

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

Other names 1

  • Jefferson Healthcare Port Ludlow 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
O20170818002250 WA Part A Provider - Rural Health Clinic 4789593708 Practice locations: Port Ludlow, WA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1801188073. Details of each certification follow.

Rural health clinic certification: CCN 508572

Legal name
JEFFERSON COUNTY PUBLIC HOSPITAL DISTRICT NO 2
Doing business as
JEFFERSON HEALTHCARE PORT LUDLOW CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Nov 8, 2017
Last certification
Nov 8, 2017
Ownership / control type
Non-profit – church related
Organization structure
CorporationNon-profit
Enrollment address
89 Breaker LN
Port Ludlow, WA 98365
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.

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
50D2029210Jefferson Healthcare Port Ludlow Clinic89 Breaker LN, Port Ludlow, WA 98365Provider-performed microscopyApr 4, 2028

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

1274 7th St
#A
Port Townsend, WA 98368
Phone (360) 385-2204

915 Sheridan St
Port Townsend, WA 98368
Phone (360) 379-8031

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 DirectorBoard Member Jan 1, 2018 100%
Operational/Managerial ControlBoard Member Jan 1, 2018 100%
Cornelis Kolff Individual Corporate DirectorBoard Member Jan 1, 2016 100%
Operational/Managerial ControlBoard Member Jan 1, 2016 100%
Tyler Freeman Individual Corporate DirectorCfo Apr 19, 2021
Operational/Managerial ControlCfo Apr 19, 2021
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 Member Jan 1, 2014 100%
Operational/Managerial ControlBoard Member Jan 1, 2014 100%
Lawrence M Glenn Individual Corporate OfficerCeo Oct 4, 2010
Corporate DirectorCeo Oct 4, 2010 100%
Operational/Managerial ControlCeo Oct 4, 2010 100%
Jill E Buhler Individual Corporate DirectorBoard Member Mar 2, 1995 100%
Operational/Managerial ControlBoard Member Mar 2, 1995 100%
Marie L Dressler Individual Corporate DirectorBoard Member Jan 1, 2010 100%
Operational/Managerial ControlBoard Member Jan 1, 2010 100%

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 48

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 48

NPI Registry JSON

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

{
    "created_epoch": "1304640000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1767139200000",
    "number": "1801188073",
    "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",
            "fax_number": "360-379-2282"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "89 BREAKER LN",
            "city": "PORT LUDLOW",
            "state": "WA",
            "postal_code": "983659766",
            "telephone_number": "360-385-2200",
            "fax_number": "360-379-2282"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "JEFFERSON COUNTY PUBLIC HOSPITAL DISTRICT NO 2",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-05-06",
        "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": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Jefferson Healthcare Port Ludlow Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Port Ludlow, WA

Sources for this page

Verify at the official NPI Registry.