MEDICARE: JACOB DONOVAN LISHNOFF

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1821945833
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB DONOVAN LISHNOFF

Provider Business Mailing Address
First Line	:	426 HIGHLAND LAKE CIR
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30033-3444
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	659 AUBURN AVE NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30312-5412
Country	:	US
Telephone Number	:	404-829-4629
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/11/2026
Last Update Date	:	03/11/2026

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Directions to “ JACOB DONOVAN LISHNOFF ” Practice Location

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