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	224Z00000X	Occupational Therapy Assistant
2	225100000X	Physical Therapist
3	225200000X	Physical Therapy Assistant
4	235Z00000X	Speech-Language Pathologist
5	225X00000X	Occupational Therapist

General Provider Information

NPI Number	:	1942002654
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	:	6436 S US HIGHWAY 85-87 STE U
Second Line	:
City	:	FOUNTAIN
State	:	CO
Zip	:	80817-1007
Country	:	US
Telephone Number	:	719-597-0822
Fax Number	:	719-599-4606

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

Provider Enumeration Date	:	03/25/2025
Last Update Date	:	03/25/2025

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Directions to “BUCK JACK, LLC ” Practice Location

Language	Start Address	Practice Location

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