Healthcare Provider Details

I. General information

NPI: 1104634385
Provider Name (Legal Business Name): BUCK JACK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2024
Last Update Date: 12/20/2024
Certification Date: 12/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6190 BARNES RD
COLORADO SPRINGS CO
80922-2600
US

IV. Provider business mailing address

2233 ACADEMY PL STE 200
COLORADO SPRINGS CO
80909-1666
US

V. Phone/Fax

Practice location:
  • Phone: 719-597-0822
  • Fax: 719-599-4606
Mailing address:
  • Phone: 719-597-0822
  • Fax: 719-599-4606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: TANNER HALL
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 719-597-0822