MEDICARE: BUCK JACK, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	103K00000X	Behavior Analyst
2	106S00000X	Behavior Technician
3	224Z00000X	Occupational Therapy Assistant
4	225100000X	Physical Therapist
5	225200000X	Physical Therapy Assistant
6	235Z00000X	Speech-Language Pathologist
7	225X00000X	Occupational Therapist

General Provider Information

NPI Number	:	1073491429
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BUCK JACK, LLC

Provider Business Mailing Address
First Line	:	2233 ACADEMY PL STE 200
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80909-1666
Country	:	US
Telephone Number	:	719-597-0822
Fax Number	:	719-599-4606

Provider Business Practice Location Address
First Line	:	4025 CLUB MANOR DR
Second Line	:
City	:	PUEBLO
State	:	CO
Zip	:	81008-2004
Country	:	US
Telephone Number	:	719-597-0822
Fax Number	:

Authorized Official
Title or Position	:	INTERNAL OPERATIONS MANAGER
Name	:	TANNER HALL
Credential	:
Telephone Number	:	719-597-0822

Provider Enumeration Date	:	08/25/2025
Last Update Date	:	08/25/2025

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Directions to “BUCK JACK, LLC ” Practice Location

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