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NPI Code Detail

MEDICARE: BUCK JACK, LLC

MEDICARE: BUCK JACK, LLC
Medicare Provider Information

Scope of Practice

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

# Taxonomy Code Taxonomy License Number License Number State
1103K00000XBehavior Analyst
2106S00000XBehavior Technician
3224Z00000XOccupational Therapy Assistant
4225100000XPhysical Therapist
5225200000XPhysical Therapy Assistant
6225X00000XOccupational Therapist
7235Z00000XSpeech-Language Pathologist

General Provider Information

NPI Number : 1508748187
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 :
Fax Number :
Provider Business Practice Location Address
First Line : 304 E ROUTT AVE
Second Line :
City : PUEBLO
State : CO
Zip : 81004-2122
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 : 07/23/2025
Last Update Date : 07/23/2025

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Directions to “BUCK JACK, LLC ” Practice Location

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