Provider Demographics
NPI:1730790114
Name:BUCK JACK LLC
Entity type:Organization
Organization Name:BUCK JACK LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:COLT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-410-6889
Mailing Address - Street 1:685 CITADEL DR E STE 580
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-5381
Mailing Address - Country:US
Mailing Address - Phone:713-410-6889
Mailing Address - Fax:
Practice Address - Street 1:2233 ACADEMY PL STE 200
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-1666
Practice Address - Country:US
Practice Address - Phone:719-301-0002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-11
Last Update Date:2020-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000181601Medicaid