Organization
BUCK JACK, LLC DBA THE SHANDY CLINIC
Active
Other names
woven Care
Organization subpart
No
Provider details
NPI number
Authorized official
TANNER DENN (CREDENTIALING SPECIALIST)
(719) 428-1840
Entity
Organization
Contact information
Practice address
1325 S PRAIRIE AVE, PUEBLO, CO 81005-2326
(719) 597-0822
Mailing address
2233 ACADEMY PL STE 200, COLORADO SPRINGS, CO 80909-1666
(719) 597-0822
Taxonomy
Speciality
Code
Description
License number
State
103K00000X
Behavior Analyst
Primary
—
—
103T00000X
Psychologist
—
—
106S00000X
Behavior Technician
—
—
225100000X
Physical Therapist
—
—
225X00000X
Occupational Therapist
—
—
235Z00000X
Speech-Language Pathologist
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
9000203726
—
CO
Enumeration date
03/14/2022
Last updated
02/28/2024
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