Covered Entity Details

DSH450039DF Tarrant County Hospital District d/b/a JPS Health Network (Active) - information as of 4/23/2025 10:54:13 PM

Main Details

Name

Tarrant County Hospital District d/b/a JPS Health Network

Subdivision Name

Southeast Tarrant Medical Home - Specialty Clinic

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH450039DF

Medicare Provider Number

450039

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/14/2023

Participating Start Date

7/1/2023

Participating Approval Date

6/13/2023

Last Recertification Date

8/15/2024

Contacts

Authorizing Official

Tarrant County Hospital District d/b/a JPS Health Network
Joy Parker, SVP, Operations
(817) 702-5802 Ext: 8177027143

Primary Contact

Tarrant County Hospital District d/b/a/ JPS Health Network
Nicole Shoquist, Chief Pharmacy Officer
(806) 674-2644

Addresses

Street Address

1050 W ARKANSAS LANE, STE 150
150
Arlington, TX 76013

Billing Address

JPS Health Network Central Fill Pharmacy
1500 S Main St
Fort Worth, TX 76104

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
TX	126675104	1992753222

Shipping Addresses

Shipping Address 1

JPS Health Network Central Fill Pharmacy
4701 Bryant Irvin Road North
LL215
Fort Worth, TX 76107

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH450039A	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	Southeast Tarrant Medical Home	1050 W Arkansas Lane	ARLINGTON	TX	Active
DSH450039AA	Child	DSH	TCHD D/B/A JPS HEALTH NETWORK	HEALING WINGS AIDS CENTER	1500S MAIN ST	FORT WORTH	TX	Terminated
DSH450039AB	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS HEALTH CENTER FOR WOMEN	1201 S MAIN ST	FORT WORTH	TX	Active
DSH450039AC	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS Medical Home Southwest - Eye Clinic	5001 Mesa Springs Dr	Fort Worth	TX	Active
DSH450039AD	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS Viola Pitts Behavioral Health Clinic	4701 BRYANT IRVIN ROAD NORTH	FORT WORTH	TX	Active
DSH450039AE	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS Medical Home at True Worth Place	1513 E Presidio Street	Fort Worth	TX	Active
DSH450039AF	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS SCHL-BSD HLTH CTR-WHITE SETLMT	8301 Downe Drive	White Settlement	TX	Terminated
DSH450039AG	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS SCHOOL-BASED HLTH CTR - NICHOLS	1850 BROWN BLVD.	ARLINGTON	TX	Terminated
DSH450039AH	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS SCHL-BSD HLTH CTR-GRPVNE-COLYVL	3050 TIMBERLINE DRIVE	GRAPEVINE	TX	Active
DSH450039AJ	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS SCHOOL-BASED HLTH CTR - KIDWELL	3115 W. PIPELINE ROAD	EULESS	TX	Terminated
DSH450039AK	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS SCHL-BSD HLTH CTR - FOREST OAK	3250 PECOS STREET	FORT WORTH	TX	Terminated
DSH450039AL	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS SCHOOL-BASED HLTH CTR - EVERMAN	600 TOWNLEY DRIVE	EVERMAN	TX	Terminated
DSH450039AM	Child	DSH	TARRANT COUNTY HOSPITAL DISTRICT, JOHN PETER SMITH HOSPITAL	JPS SCHL-BSD HLTH CTR-CHAPEL HILL A	4640 SYCAMORE SCHOOL ROAD	FORT WORTH	TX	Terminated
DSH450039AN	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS SCHL-BSD HLTH CTR-CSTLBRY-LKE W	5300 BUCHANAN ROAD	FORT WORTH	TX	Terminated
DSH450039AP	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS CARDIOLOGY CLINIC	1400 S Main St	Fort Worth	TX	Active
DSH450039AQ	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS SCHOOL-BSD HLTH CTR-HALTOM CITY	2807 LAYTON AVENUE	FORT WORTH	TX	Terminated
DSH450039AR	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS SCHOOL-BASED HLTH CTR-EST HILLS	5900 YOSEMITE	FORT WORTH	TX	Terminated
DSH450039AS	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS SCHL-BSD HLTH CTR-EAG MT-SAGINA	1029 N. SAGINAW BLVD.	SAGINAW	TX	Terminated
DSH450039AT	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS SCHL-BSD HLTH CTR - HEB	3115 W. PIPELINE ROAD	EULESS	TX	Terminated
DSH450039AU	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS Medical Home Northeast Tarrant Behavioral Health Clinic	3200 West Euless Blvd	Euless	TX	Active
DSH450039AV	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS HEALTH CENTER FOR WOMEN - NORTHWEST	2200 EPHRIHAM	FORT WORTH	TX	Active
DSH450039AW	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS Bardin Road Specialty Clinics	1741 E. BARDIN RD	ARLINGTON	TX	Active
DSH450039AX	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS SCHOOL BSD HLTH CTR - CROWLEY	1320 W. EVERMAN PARKWAY	FORT WORTH	TX	Terminated
DSH450039AY	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	MAGNOLIA HEALTH CENTER	1400 S Main Street	Fort Worth	TX	Active
DSH450039AZ	Child	DSH	TCHD D/B/A JPS HEALTH NETWORK	JPS FAMILY MEDICINE & URG CARE CTR / Family Medicine. Eye Clinic.	1741 E. BARDIN RD	ARLINGTON	TX	Terminated
DSH450039B	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	DIAMOND HILL COMMUNITY CLINIC	3308 DEEN ROAD	FORT WORTH	TX	Active
DSH450039BA	Child	DSH	TARRANT COUNTY HOSPITAL DISTRICT, JOHN PETER SMITH HOSPITAL	JPS G.I. - ENDOSCOPY CLINIC	1741 E. BARDIN RD	ARLINGTON	TX	Terminated
DSH450039BB	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS Health Center Stop Six Behavioral Health Clinic	3301 STALCUP RD	FORT WORTH	TX	Active
DSH450039BC	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS HEALTH CENTER-POLYTECHNIC	1650 S. BEACH STREET	FORT WORTH	TX	Active
DSH450039BD	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS HEALTH CENTER-DIAMOND HILL / Dental Clinic	3308 DEEN RD	FORT WORTH	TX	Terminated
DSH450039BE	Child	DSH	TARRANT COUNTY HOSPITAL DISTRICT, JOHN PETER SMITH HOSPITAL	JPS HEALTH CENTER-NORTHWEST	401 STRIBLING DR	AZLE	TX	Terminated
DSH450039BF	Child	DSH	TCHD D/B/A JPS HEALTH NETWORK	JPS HEALTH CENTER-EASTERN HILLS SCH	5917 SHELTON ST	FORT WORTH	TX	Terminated
DSH450039BG	Child	DSH	TARRANT COUNTY HOSPITAL DISTRICT, JOHN PETER SMITH HOSPITAL	JPS FAMILY HEALTH CENTER	1500S MAIN ST	FORT WORTH	TX	Terminated
DSH450039BH	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS SCHOOL-BASED HLTH CTR-FERGUSON	600 SE Green Oaks Blvd	Arlington	TX	Terminated
DSH450039BJ	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS SCHOOL-BASED HLTH CTR-NORTHSIDE	2011 PROSPECT AVENUE	FORT WORTH	TX	Terminated
DSH450039BK	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS SCHL-BASED HLTH CTR - MANSFIELD	1920 North Main Street	MANSFIELD	TX	Active
DSH450039BL	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	Southeast Tarrant Medical Home - Women's Clinic	1050 W Arkansas Lane	Arlington	TX	Active
DSH450039BM	Child	DSH	TCHD D/B/A JPS HEALTH NETWORK	JPS HEALTH CENTER - GRAND PRAIRIE	2737 SHERMAN STREET	GRAND PRAIRIE	TX	Terminated
DSH450039BN	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS SCHOOL-BSD HLTH CTR - BIRDVILLE	8200 O'BRIAN WAY	NORTH RICHLAND HILLS	TX	Terminated
DSH450039BP	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS School-Based Health Center - Central	604 New York Avenue	Arlington	TX	Terminated
DSH450039BQ	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	Central Arlington Behavioral Health Clinic	501 W MAIN ST	ARLINGTON	TX	Active
DSH450039BR	Child	DSH	TARRANT COUNTY HOSPITAL DISTRICT, JOHN PETER SMITH HOSPITAL	Medical Procedures Clinic	1450 8th Avenue	Fort Worth	TX	Terminated
DSH450039BS	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	Western Hills-School Based Clinic	8376 Mojave Trail	Fort Worth	TX	Terminated
DSH450039BT	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	Wound Care Clinic	1350 S Main Street	Fort Worth	TX	Active
DSH450039BU	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	Pain Management Leuda	710 W Leuda Street	Fort Worth	TX	Active
DSH450039BV	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	Correctional Health - Lamar Jail	100 N Lamar St	Fort Worth	TX	Active
DSH450039BW	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	Correctional Health - Greenbay Jail	2500 Urban Drive	Fort Worth	TX	Active
DSH450039BX	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	Trinity Springs North - Behavioral Health	1000 St Louis Ave	Fort Worth	TX	Terminated
DSH450039BY	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS Center for Behavioral Health Recovery	601 W Terrell Ave	Fort Worth	TX	Active
DSH450039BZ	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	Medical Home at Northeast Partial Hospitalization/Intensive Outpatient	3200 W Euless Blvd	Euless	TX	Active
DSH450039C	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS Medical Home Northeast	3200 West Euless Blvd	Euless	TX	Active
DSH450039CA	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	Eastern Hills School Based Clinic Behavioral Health - Behavioral Health	5900 Yosemite Drive	Fort Worth	TX	Terminated
DSH450039CB	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS Stop Six IOP - Behavioral Health	3301 Stalcup Rd	Fort Worth	TX	Terminated
DSH450039CC	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS JSCA Diagnostic - Radiology	4400 New York Avenue	Arlington	TX	Active
DSH450039CD	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS Medicine Specialty Clinics 1400 - Specialty Clinics	1400 South Main Street	Fort Worth	TX	Active
DSH450039CE	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	Southeast Tarrant Medical Home - JPS Southeast CHC	1050 W Arkansas Lane	Arlington	TX	Terminated
DSH450039CF	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS Leuda Pain Management - Radiology	710 W Leuda Street	Fort Worth	TX	Active
DSH450039CG	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS Care Connections Clinic - Primary Care	1400 S Main Street	Fort Worth	TX	Terminated
DSH450039CH	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS Viola Pitts/Como Dental Clinic - Dental	4701 Bryant Irvin Road North	Fort Worth	TX	Terminated
DSH450039CJ	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	Stop Six Community Health Clinic Dental - Dental	3301 Stalcup	Fort Worth	TX	Terminated
DSH450039CK	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	Diamond Hill Community Clinic - Eye Clinic	3308 Deen Road	Fort Worth	TX	Active
DSH450039CL	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS Medical Home at True Worth Place Dental Clinic - Dental	1513 E Presidio Street	Fort Worth	TX	Terminated
DSH450039CM	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	Southeast Tarrant Medical Home Dental Clinic - Dental	1050 W Arkansas Lane	Arlington	TX	Terminated
DSH450039CN	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS Bardin Rd - Radiology	1741 E Bardin Rd	Arlington	TX	Active
DSH450039CP	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS Medical Home Northeast Dental Clinic - Dental	3200 West Euless Blvd	Euless	TX	Terminated
DSH450039CQ	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	Central Arlington Partial Hospitalization/Intensive Outpatient	501 W Main Street	Fort Worth	TX	Active
DSH450039CR	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	Healing Wings Clinic - Behavioral Health	1350 South Main Street	Fort Worth	TX	Active
DSH450039CS	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	True Worth Behavioral Health Clinic	1513 E Presidio Street	Fort Worth	TX	Active
DSH450039CT	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	Southeast Tarrant Medical Home - Eye Clinic	1050 W Arkansas Lane	Arlington	TX	Active
DSH450039CU	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS Partial Hospitalization/Intensive Outpatient	601 W Terrell Ave	Fort Worth	TX	Active
DSH450039CV	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	Correctional Health - Lon Evans	600 W Weatherford St	Fort Worth	TX	Active
DSH450039CW	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS Medical Home Northeast Tarrant - Eye Clinic - Optometry	3200 West Euless Blvd	Euless	TX	Active
DSH450039CX	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	Viola Pitts Partial Hospitalization/Intensive Outpatient	4701 Bryant Irvin Road North	Fort Worth	TX	Active
DSH450039CY	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	Correctional Health - Belknap	350 W Belknap St	Fort Worth	TX	Active
DSH450039CZ	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	Correctional Health - Cold Springs	1815 Cold Springs Rd	Fort Worth	TX	Terminated
DSH450039D	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	STOP SIX COMMUNITY HEALTH CLINIC	3301 STALCUP RD	FORT WORTH	TX	Active
DSH450039DA	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JSCA - Endoscopy	4400 New York Ave	Arlington	TX	Active
DSH450039DB	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	Correctional Health - Intake - Correctional Health	100 N Lamar St	Fort Worth	TX	Active
DSH450039DD	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	Oncology Radiology	1450 8th Avenue	Fort Worth	TX	Active
DSH450039DE	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS Oncology Clinic - Oncology	1450 8th Avenue	Fort Worth	TX	Active
DSH450039DF	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	Southeast Tarrant Medical Home - Specialty Clinic	1050 W ARKANSAS LANE, STE 150	Arlington	TX	Active
DSH450039DG	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	Correctional Health - Clinic - Correctional Health	600 W Weatherford St	Fort Worth	TX	Active
DSH450039DH	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	Correctional Health - Infirmary - Correctional Health	600 W Weatherford St	Fort Worth	TX	Active
DSH450039DJ	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS Oncology - CT	1450 8th Avenue	Fort Worth	TX	Active
DSH450039DK	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS Stop Six Health Center - Behavioral Health Co-Occurring Clinic	3301 Stalcup Rd	Fort Worth	TX	Active
DSH450039DL	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JSCA Pre-Admission Testing - PAT	4400 New York Avenue	Arlington	TX	Active
DSH450039DM	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	Correctional Health - Operations	100 N Lamar St	Fort Worth	TX	Active
DSH450039DN	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	Southeast Tarrant Medical Home - Behavioral Health	1050 W Arkansas Lane	Arlington	TX	Active
DSH450039F	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS Oncology and Infusion Center	1450 8th Avenue	Fort Worth	TX	Active
DSH450039G	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	VIOLA PITTS/COMO CLINIC	4701 BRYANT IRVIN NORTH	FORT WORTH	TX	Active
DSH450039H	Child	DSH	TARRANT COUNTY HOSPITAL DISTRICT, JOHN PETER SMITH HOSPITAL	JPS OUTPATIENT CLINIC	1500 SOUTH MAIN ST, STE OPC-1	FORT WORTH	TX	Terminated
DSH450039I	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	NORTHWEST COMMUNITY CLINIC	401 Stribling Dr	Azle	TX	Active
DSH450039J	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	GERTRUDE TARPLEY COMMUNITY CLINIC	6601 WATAUGA ROAD	WATAUGA	TX	Active
DSH450039K	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS Medical Home Southwest	5001 Mesa Springs Dr	Fort Worth	TX	Active
DSH450039L	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JSCA-Operating Room	4400 New York Ave	Arlington	TX	Active
DSH450039M	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JSCA-Post Anesthesia Care Unit	4400 New York Ave	Arlington	TX	Active
DSH450039N	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JSCA-Anesthesiology	4400 New York Avenue	Arlington	TX	Active
DSH450039Q	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS Health Connect Clinic	1400 S Main Street	Fort Worth	TX	Active
DSH450039R	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	Employee Health Clinic	1350 South Main Street	Fort Worth	TX	Active
DSH450039S	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS SCHOOL-BSD HLTH CTR - SOUTHSIDE	2115 HEMPHILL STREET	FORT WORTH	TX	Terminated
DSH450039T	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	HEALING WINGS	1350 S. MAIN STREET	FORT WORTH	TX	Active
DSH450039U	Child	DSH	TARRANT COUNTY HOSPITAL DISTRICT, JOHN PETER SMITH HOSPITAL	JPS WORTH HEIGHTS DENTAL CLINIC	3551 NEW YORK AVENUE	FORT WORTH	TX	Terminated
DSH450039V	Child	DSH	TCHD D/B/A JPS HEALTH NETWORK	JPS HEALTH CENTER-ARLINGTON / Family Medicine. Dental Clinic.	601W SANFORD ST	ARLINGTON	TX	Terminated
DSH450039W	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	ORTHOPEDIC & SPORTS MEDICINE CLINIC	1741 E Bardin Rd	Arlington	TX	Terminated
DSH450039X	Child	DSH	TCHD D/B/A JPS HEALTH NETWORK	JPS HEALTH CENTER-CENTRAL ARLINGTON / Family Medicine. Behavioral Health.	501W MAIN ST	ARLINGTON	TX	Terminated
DSH450039Y	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS PEDIATRIC CLINIC	1400 S MAIN ST	FORT WORTH	TX	Active
DSH450039Z	Child	DSH	Tarrant County Hospital District d/b/a JPS Health Network	JPS Medicine Specialty Clinics 1350	1350 South Main Street	Fort Worth	TX	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	Shoquist, Nicole Chief Pharmacy Officer Tarrant County Hospital District d/b/a/ JPS Health Network 8177025744	Shoquist, Nicole Chief Pharmacy Officer Tarrant County Hospital District d/b/a/ JPS Health Network 8066742644	3/17/2025 7:35 PM
Details	Last Recertification Date	Update	Recertification	8/29/2023 4:18:58 PM	8/15/2024 11:49:56 AM	8/15/2024 11:49 AM
Contacts	Authorizing Official	Update	Profile Change Request	Parker, Joy VP, Operations Tarrant County Hospital District d/b/a JPS Health Network 8177025802-8177027143	Parker, Joy SVP, Operations Tarrant County Hospital District d/b/a JPS Health Network 8177025802-8177027143	7/16/2024 6:32 AM
Contacts	Signed By	Update	Profile Change Request	Parker, Joy VP, Operations Tarrant County Hospital District d/b/a JPS Health Network 8177025802-8177027143	Parker, Joy SVP, Operations Tarrant County Hospital District d/b/a JPS Health Network 8177025802-8177027143	7/16/2024 6:32 AM
Contacts	Primary Contact	Update	Profile Change Request	Shoquist, Nicole Chief Pharmacy Officer Tarrant County Hospital District d/b/a/ JPS Health Network 8177026718	Shoquist, Nicole Chief Pharmacy Officer Tarrant County Hospital District d/b/a/ JPS Health Network 8177025744	7/15/2024 5:24 PM
Details	Last Recertification Date	Update	Recertification		8/29/2023 4:18:58 PM	8/29/2023 4:18 PM
Details	Entity Subname	Update	Recertification	Southeast Tarrant Medical Home - Specialty Clinic - Specialty Services	Southeast Tarrant Medical Home - Specialty Clinic	8/29/2023 4:18 PM
Details	State	Update		Approved	Active	7/1/2023 12:01 AM
Addresses	Main Address	Insert	New Registration		1050 W ARKANSAS LANE, STE 150 150 Arlington, TX 76013	6/13/2023 12:07 PM
Addresses	Billing Address	Insert	New Registration		JPS Health Network Central Fill Pharmacy 1500 S Main St Fort Worth, TX 76104	6/13/2023 12:07 PM
Contacts	Signed By	Insert	New Registration		Parker, Joy VP, Operations Tarrant County Hospital District d/b/a JPS Health Network 8177025802-8177027143	6/13/2023 12:07 PM
Details	340B ID	Update	New Registration		DSH450039DF	6/13/2023 12:07 PM
Details	Entity Subname	Update	New Registration	Southeast Tarrant Medical Home - Specialty Clinic	Southeast Tarrant Medical Home - Specialty Clinic - Specialty Services	6/13/2023 12:07 PM
Dates	Participating Approval Date	Update	New Registration		6/13/2023 12:07:09 PM	6/13/2023 12:07 PM
Details	State	Update	New Registration	Pending	Approved	6/13/2023 12:07 PM
Dates	Signed By Date	Update	New Registration		5/17/2023 12:07:32 PM	6/13/2023 12:07 PM
Dates	Start Date	Update	New Registration		7/1/2023 12:00:00 AM	6/13/2023 12:07 PM
Addresses	Main Address	Insert	New Registration		1050 W ARKANSAS LANE, STE 150 150 Arlington, TX 76013	4/14/2023 12:21 PM
Addresses	Billing Address	Insert	New Registration		JPS Health Network Central Fill Pharmacy 4701 Bryant Irvin Road North LL215 Fort Worth, TX 76107	4/14/2023 12:21 PM
Addresses	Shipping Address	Insert	New Registration		JPS Health Network Central Fill Pharmacy 4701 Bryant Irvin Road North LL215 Fort Worth, TX 76107	4/14/2023 12:21 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/14/2023 12:21 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		126675104	4/14/2023 12:21 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	4/14/2023 12:21 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1992753222	4/14/2023 12:21 PM
Medicaid Billing	NPI: State	Insert	New Registration		TX	4/14/2023 12:21 PM
Contacts	Primary Contact	Insert	New Registration		Shoquist, Nicole Chief Pharmacy Officer Tarrant County Hospital District d/b/a/ JPS Health Network 8177026718	4/14/2023 12:21 PM
Contacts	Authorizing Official	Insert	New Registration		Parker, Joy VP, Operations Tarrant County Hospital District d/b/a JPS Health Network 8177025802-8177027143	4/14/2023 12:21 PM
Details	Assistance Received From Date	Insert	New Registration			4/14/2023 12:21 PM
Details	Assistance Received To Date	Insert	New Registration			4/14/2023 12:21 PM
Details	Last Recertification Date	Insert	New Registration			4/14/2023 12:21 PM
Details	Grant Number	Insert	New Registration			4/14/2023 12:21 PM
Details	340B ID	Insert	New Registration			4/14/2023 12:21 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/14/2023 12:21 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/14/2023 12:21 PM
Details	Medicare Provider Number	Insert	New Registration		450039	4/14/2023 12:21 PM
Details	Entity Name	Insert	New Registration		Tarrant County Hospital District d/b/a JPS Health Network	4/14/2023 12:21 PM
Details	NOFO Number	Insert	New Registration			4/14/2023 12:21 PM
Details	Program Code	Insert	New Registration		DSH	4/14/2023 12:21 PM
Details	Entity Subname	Insert	New Registration		Southeast Tarrant Medical Home - Specialty Clinic	4/14/2023 12:21 PM
Dates	Participating Approval Date	Insert	New Registration			4/14/2023 12:21 PM
Details	State	Insert	New Registration		Pending	4/14/2023 12:21 PM
Dates	Registration Date	Insert	New Registration		4/14/2023 12:21:28 PM	4/14/2023 12:21 PM
Dates	Signed By Date	Insert	New Registration			4/14/2023 12:21 PM
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