Healthcare Provider Details

I. General information

NPI: 1891630224
Provider Name (Legal Business Name): JEFFERY WAYNE COOMER CRC, CFRC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2026
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52 E WASHINGTON AVE
PERU IN
46970-1007
US

IV. Provider business mailing address

52 E WASHINGTON AVE
PERU IN
46970-1007
US

V. Phone/Fax

Practice location:
  • Phone: 765-431-8114
  • Fax:
Mailing address:
  • Phone: 765-431-8114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberCFRC-5002
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberCARC-5030
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: