Healthcare Provider Details

I. General information

NPI: 1629704861
Provider Name (Legal Business Name): FIT JAM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2022
Last Update Date: 07/29/2022
Certification Date: 07/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 S MAIN ST STE 20
PETAL MS
39465-2203
US

IV. Provider business mailing address

509 S MAIN ST STE 20
PETAL MS
39465-2203
US

V. Phone/Fax

Practice location:
  • Phone: 601-336-4144
  • Fax:
Mailing address:
  • Phone: 601-336-4144
  • Fax: 601-582-7697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: ANTHONY LEE EVANS
Title or Position: OWNER
Credential:
Phone: 662-836-6528