NPIMap

Organization Active NPI

Agape Community Health Center, Inc.

  • Federally Qualified Health Center (FQHC)
  • Jacksonville, FL
National Provider Identifier
1962867762
Registry record updated Sep 9, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
N04000004094 Issued in FL
Legal business name
AGAPE COMMUNITY HEALTH CENTER, INC.
Practice address
120 King St
Jacksonville, FL 32204-2410
Phone
(904) 760-4904
Fax
(904) 930-4607
NPI assigned
Dec 21, 2015
Last updated
Sep 9, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 9, 2020

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

Authorized official

Name
Ms. Mia L Jones
Title
Ceo
Phone
(904) 253-1069

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X N04000004094 FL Primary

Addresses

Primary practice location

120 King St
Jacksonville, FL 32204-2410

Mailing address

120 King St
Jacksonville, FL 32204-2410
Phone (904) 760-4904

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20050331000177 FL Part B Supplier - Clinic/Group Practice 3476500695 Receives reassigned benefits from 28 practitioners
4 other NPIs on this enrollment
Practice locations: Jacksonville, FL
O20161017000119 FL Part A Provider - Federally Qualified Health Center (FQHC) 3476500695 Practice locations: Jacksonville, FL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1962867762. Details of each certification follow.

Federally qualified health center certification: CCN 681073

Legal name
AGAPE COMMUNITY HEALTH CENTER, INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 3, 2016
Last certification
Nov 3, 2016
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Apr 16, 2004 in FL
Enrollment address
120 King St
West Jax
Jacksonville, FL 32204-2410

Other NPIs with the same Medicare PAC ID 2

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

Other NPIs on the same Medicare enrollment 3

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

National Provider Directory

National Provider Directory
Tax ID family
Agape Community Health Center Inc13 organizations share this tax ID, including this one

Other organizations with this tax ID 12

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

Locations

1680 Dunn Ave
Ste 3437
Jacksonville, FL 32218
Phone (904) 760-4964

3900 University Blvd S
#2
Jacksonville, FL 32216

3900 University Blvd S
Ste 200
Jacksonville, FL 32216

Ownership & related parties

All disclosed owners & managing parties 1

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

NameRoleSinceShare
Mia Jones Individual Corporate OfficerCeo Apr 1, 2016
W-2 Managing Employee Apr 1, 2016

Practitioners & affiliated clinicians

Practitioners 28

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 28

NPI Registry JSON

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

{
    "created_epoch": "1450656000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1599609600000",
    "number": "1962867762",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "120 KING ST",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322042410",
            "telephone_number": "904-760-4904"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "120 KING ST",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322042410",
            "telephone_number": "904-760-4904",
            "fax_number": "904-930-4607"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "AGAPE COMMUNITY HEALTH CENTER, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-12-21",
        "last_updated": "2020-09-09",
        "certification_date": "2020-09-09",
        "status": "A",
        "authorized_official_last_name": "JONES",
        "authorized_official_first_name": "MIA",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "904-253-1069",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "FL",
            "license": "N04000004094",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Jacksonville, FL

Sources for this page

Verify at the official NPI Registry.