Healthcare Provider Details

I. General information

NPI: 1194642751
Provider Name (Legal Business Name): JASON HUMPHRIES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2165 REYNOLDS RIDGE LN APT 307
FORT MILL SC
29708-2103
US

IV. Provider business mailing address

2165 REYNOLDS RIDGE LN APT 307
FORT MILL SC
29708-2103
US

V. Phone/Fax

Practice location:
  • Phone: 803-804-2622
  • Fax:
Mailing address:
  • Phone: 803-558-9924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146L00000X
TaxonomyParamedic
License NumberSC007262
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code146E00000X
TaxonomyCommunity Paramedic
License Number991
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: