Provider Demographics
NPI:1720541261
Name:WOODBURY, JACK (RBT)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:WOODBURY
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4815 LIST DR STE 107
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-3340
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4815 LIST DR STE 107
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-3340
Practice Address - Country:US
Practice Address - Phone:214-901-4196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-11
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-19-83849103K00000X
CORBT-1983849106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst