Organization
BUCK JACK LLC
Active
Other names
The Shandy Clinic
Organization subpart
No
Provider details
NPI number
Authorized official
WILLIAM COLT (PRESIDENT)
(713) 410-6889
Entity
Organization
Contact information
Practice address
8540 SCARBOROUGH DR STE 300, COLORADO SPRINGS, CO 80920-7581
(719) 822-0900
Mailing address
685 CITADEL DR E STE 580, COLORADO SPRINGS, CO 80909-5381
(719) 597-0822
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
9000181601
—
CO
Enumeration date
09/04/2020
Last updated
09/04/2020
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