Healthcare Provider Details

I. General information

NPI: 1518872548
Provider Name (Legal Business Name): DEVORA JIMENEZ DOMINGO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2026
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14207 E 14TH ST
SAN LEANDRO CA
94578-2709
US

IV. Provider business mailing address

129 BREED AVE
SAN LEANDRO CA
94577-1811
US

V. Phone/Fax

Practice location:
  • Phone: 510-220-9578
  • Fax:
Mailing address:
  • Phone: 510-934-0650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: