Healthcare Provider Details

I. General information

NPI: 1205624111
Provider Name (Legal Business Name): BUCK JACK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2025
Last Update Date: 04/29/2025
Certification Date: 04/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 E ROUTT AVE
PUEBLO CO
81004-2122
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 Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: TANNER HALL
Title or Position: INTERNAL OPERATIONS MANAGER
Credential:
Phone: 719-597-0822