Healthcare Provider Details

I. General information

NPI: 1710474655
Provider Name (Legal Business Name): STEFANIA BACCINO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2018
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 W FOREST AVE FL 5
JACKSON TN
38301-3937
US

IV. Provider business mailing address

257 BANCORP SOUTH PKWY
JACKSON TN
38305-7582
US

V. Phone/Fax

Practice location:
  • Phone: 731-423-1932
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number66237
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: