# BUCK JACK, LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** THE SHANDY CLINIC
- **Organization subpart:** No

## Provider details

- **NPI number:** 1538837794
- **Authorized official:** TANNER DENN (CREDENTIALING MANAGER)
- **Authorized official phone:** (719) 428-1840

## Contact information

- **Practice address:** 685 CITADEL DR E STE 580, COLORADO SPRINGS, CO 80909-5381
- **Practice address phone:** (719) 597-0822
- **Practice address fax:** (719) 599-4606
- **Mailing address:** 685 CITADEL DR E STE 580, COLORADO SPRINGS, CO 80909-5381
- **Mailing address phone:** (719) 597-0822
- **Mailing address fax:** (719) 599-4606

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 103K00000X | Behavior Analyst | — | NULL | — |
| 103K00000X | Behavior Analyst | — | — | — |
| 103T00000X | Psychologist | — | NULL | — |
| 103T00000X | Psychologist | — | — | — |
| 225100000X | Physical Therapist | — | NULL | — |
| 225100000X | Physical Therapist | — | — | — |
| 225X00000X | Occupational Therapist | — | NULL | — |
| 225X00000X | Occupational Therapist | — | — | — |
| 235Z00000X | Speech-Language Pathologist | — | NULL | — |
| 235Z00000X | Speech-Language Pathologist | — | — | — |
| 251E00000X | Home Health Agency | — | NULL | Yes |

## Other

- **Enumeration date:** 09/02/2021
- **Last updated:** 09/02/2021