Provider Demographics
NPI:1396628681
Name:PEACE OUTPOST
Entity type:Organization
Organization Name:PEACE OUTPOST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-335-5339
Mailing Address - Street 1:628 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70802-5342
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1423 E WILLOW ST APT 5
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70501-3834
Practice Address - Country:US
Practice Address - Phone:337-254-0675
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-26
Last Update Date:2025-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical TechniciansGroup - Multi-Specialty