Healthcare Provider Details

I. General information

NPI: 1770417263
Provider Name (Legal Business Name): MR. JACOB MICHAEL LISAK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 N MADISON ST
MARSHALL MI
49068-1199
US

IV. Provider business mailing address

319 S CAPITAL AVE
ATHENS MI
49011-9335
US

V. Phone/Fax

Practice location:
  • Phone: 269-789-3862
  • Fax: 269-789-8126
Mailing address:
  • Phone: 269-789-3862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34009044A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801108553
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: